Medicare Advantage Prescription Drug Plan is one of the Medicare options available to you. MAPD plans roll all your benefits into a single option. These plans are similar to a group employer plan. They include copays, coinsurance, and sometimes deductibles. MAPD plans can also offer additional benefits not covered by Original Medicare.

Types of Medicare Advantage Prescription Drug Plans (MAPD)

MAPD plans come in several shapes and sizes. Your options include HMO, PPO, and PFFS.

Health Maintenance Organization (HMO)

HMO plans work with specific networks and doctors. Some people view this as a negative. The intention behind this model of care is to lower your healthcare costs. They negotiate with in-network providers to get the best prices for you.

An HMO’s model of care revolves around your primary care provider (PCP). Your PCP will coordinate your care. The PCP’s job is to keep you healthy. If you need tests, procedures, or to see a specialist, your PCP will provide a referral.

HMO plans usually have the most robust benefits, including lower copays and maximum out-of-pocket (MOOP) costs. They include more plan extras than other types of Medicare Advantage Prescription Drug plans.

If you have a few services you’d like to use out of network, consider an HMO-POS. These HMO plans allow certain benefits out of the network, usually with a higher cost-share. The out-of-network benefits vary. Make sure you look at the plan materials from each HMO-POS to see if the service you need out of network is covered.

Preferred Provider Organization (PPO)

PPO plans give you more flexibility of providers. PPO plans allow you to use providers in-network or out-of-network. Using in-network providers will be a lower cost, but you have the option to see any provider that takes Medicare.

Out-of-network providers usually have a higher copay. There could be cases where an out-of-network provider will require you to pay the total cost. You can submit it to your insurance carrier for reimbursement.

The maximum out-of-pocket costs are high on a PPO. They usually range from $6,700 (in-network) to $10,000 (out-of-network).

Private-Fee-For-Service (PFFS)

Private-Fee-For-Service plans can come with or without drug coverage. Selecting a version without drug coverage requires you to pick up a part D plan. Not doing so could result in a monetary penalty for Part D.

PFFS plans are rare and not available in many areas. Rural areas are the most common location for these.

If you choose a PFFS plan, you don’t have to use network providers. You can use any provider that accepts Medicare, provided they agree to the terms and conditions of the plan before each visit or procedure.

If the Private-Fee-For-Service plan you choose has a network option, you wouldn’t have to verify with the in-network providers as they have agreed to accept the plan.

How to Choose the Right MAPD Plan?

Everyone has a different situation. You have to look at a few things to determine which plan is right for you.

What’s more important to you? Low costs or freedom of networks

Some people are afraid of networks due to a negative experiences in the past. Other people have had great success with networks. It’s a personal decision that no one can make for you. Many people prefer to have lower costs and exposure when they start Medicare.

Many Medicare beneficiaries feel this way due to being on a fixed retirement income. If you want lower out-of-pocket costs, an HMO is the way to go. If you want freedom of providers, select a PPO.

Do you have a condition that requires travel for certain specialists?

If you have specialists that don’t take HMO plans, a PPO might be your best option.

Do you travel for extended periods?

Regardless of what you choose, you have coverage for an emergency, even out of the network. However, if you’re a frequent traveler that spends months away from home a PPO, or PFFS may be a better option. PPOs and PFFS plans allow you to see a primary care physician no matter where you are without referrals.

Sometimes carriers will have suitcase programs that allow you to see a provider as in-network when traveling. To find a provider in another state that would see you as in-network, you’ll need to call the customer service number on the back of your insurance card. They’ll help determine if you have a suitcase program and find an in-network provider.

Do you want the most comprehensive coverage?

HMO plans typically give the most plan extras and larger allowances on the extra programs and services they provide. If you want the most additional programs and services, this is the way to go.

How to Get Help Enrolling in a Medicare Advantage Prescription Drug Plan

Call us or fill out our online request form. We have licensed agents that can assist you with the needs assessment. Our agents have access to the plans in your area to give an unbiased look at all the options available to you.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.