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Not all zero-premium plans are the same

For those who have elected Medicare Advantage, there are zero premium plans that include drug coverage. The premiums may be the same but realize that costs and coverage can vary considerably. Let’s look at some results from the Medicare Plan Finder for Susan. She has diabetes and takes three brand-name drugs. Here are some findings from three zero-premium plans in her area. 

Plan 1, HMO (health maintenance organization):

  • Annual drug costs $1,865
  • Out-of-pocket limit $5,000 in-network services (no coverage for out-of-network care)
  • Co-payment for a specialist’s visit $45
  • Inpatient hospital stay days 1-7 $310 co-pay 
  • Authorization rules for 22 services
  • Referral rules for 13 services
  • Quality rating 4 stars

Plan 2, PPO (preferred provider organization):

  • Annual drug costs $2,490
  • Out-of-pocket limit $6,700 in-network services and $10,000 in- and out-of-network combined
  • Co-payment for a specialist’s visit $50 in-network, 50% out-of-network
  • Inpatient hospital stay days 1-6 $395/day in-network, 50% per stay out-of-network
  • Authorization rules for 27 services
  • Quality rating 3.5 stars

The differences are not all that great but over time, and depending on the circumstances, costs can add up. The best strategy: Add up the costs for the services you believe you’ll use. Then dig into the details of each plan.

Last updated: 03-01-2021