Key takeaways:
A Medicare Advantage plan can be a cost-effective, private alternative to original Medicare if you choose a plan that fits your needs.
When you’re shopping around, examine the prescription medication coverage that’s bundled into the Medicare Advantage plans that you’re considering or compare Part D prescription plans if you need to buy one separately.
Unlike original Medicare, most Medicare Advantage plans include prescription coverage, all have out-of-pocket limits, and some require no premium beyond what you already pay for Medicare Part B.
If you become eligible for Medicare, you can elect original Medicare (Part A and/or Part B) or choose a Medicare Advantage plan, also known as Part C.
Medicare recently passed a tipping point between traditional coverage and alternative private plans known as Medicare Advantage. For the first time, Medicare Advantage has more enrollees than original Medicare. A Centers for Medicare & Medicaid Services (CMS) dashboard tracking enrollment shows that 51% of the 70 million people with Medicare had Medicare Advantage, versus 49% with original Medicare, in January 2026.
Medicare Advantage open enrollment happens each year from January 1 to March 31. If you want to switch from original Medicare to a Medicare Advantage plan, you have to make that adjustment during the Medicare open enrollment period from October 15 to December 7.
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For many people, Medicare Advantage plans offer an attractive alternative to original Medicare because they cover all of the same hospital and medical services while offering extra benefits, such as vision, dental, and prescription coverage. Also, out-of-pocket costs may be lower for people enrolled in Medicare Advantage plans.
However, overlooking important details when opting for a private Medicare plan can be a costly misstep. Here are 6 focus areas to explore when considering a Medicare Advantage plan:
Zero-premium plans
With Medicare Advantage plans, you still pay your original Medicare Part B premium, and it’s usually deducted from your monthly Social Security payment. In 2026, the Part B premium is $202.90 per month for most people and up to $689.90 for people with higher incomes.
Some Medicare Advantage plans require an additional premium, but there are “zero-premium” Medicare Advantage plans — which allow you to have more benefits than original Medicare without paying a higher premium. These plans have become more widely available. In 2025, 76% of Medcare Advantage plans with prescription coverage were considered zero-premium.
With zero-premium plans, you remain responsible for meeting your deductible as well as copays and coinsurance, but you have an out-of-pocket limit on those costs.
Out-of-pocket limits
Unless you have a Medicare supplement plan (Medigap), original Medicare has no cap on what you can spend out of pocket. But Medicare Advantage plans do.
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Out-of-pocket limits among Medicare Advantage plans vary, but there is a maximum amount set every year for all plans. In 2026, the out-of-pocket maximum for Medicare Advantage plans is $9,250 for in-network services, or $13,900 for in-network and out-of-network services combined. You cannot use Medigap with a Medicare Advantage plan.
Pros and cons of extra benefits
Medicare Advantage plans offer many benefits that original Medicare doesn’t. While Medicare Advantage plans typically cap extra benefits, you could potentially get coverage for:
Dental care, including dentures
Hearing care, including hearing aids
Meals
Vision care, including eye exams and glasses
Depending on the care you need, choosing a Medicare Advantage plan with an additional premium may be worth considering. But spending the extra money doesn’t make sense for everyone.
Part D prescription coverage
The wrong Part D prescription plan — either standalone or rolled into a Medicare Advantage plan — could end up costing you hundreds of dollars more than a plan that covers the medications you need.
That’s why it’s important to review the formulary for prescription coverage bundled in your Medicare Advantage plan or any separate Part D plan you’re considering. You should look for prescription insurance that covers your medications in the lowest (and least costly) tiers possible.
Most Medicare Advantage plans, but not all, include Part D coverage. If the Medicare Advantage plan you choose does not include prescription coverage, you can buy a stand-alone Part D plan. The average Part D premium for a standalone plan is $34.50 a month in 2026.
You can enter your medications in the Medicare Plan Finder tool to generate suggested Part D plans that would be best for you.
Medicare Part D changes in 2026
In 2026, there are several important updates to Part D that can help enrollees save money or manage out-of-pocket costs:
$2,100 out-of-pocket limit: In 2024, there was an $8,000 out-of-pocket cap that dropped to $2,000 in 2025. You’ll need to spend $2,100 on covered medications in 2026 before your cost sharing ends and your plan pays at 100%.
Medicare Prescription Payment Plan: This payment option, which debuted in 2025, lets you spread your costs for covered prescriptions over the year. The plan won’t save you money, but monthly payments can help you manage expenses during a coverage year. You can also avoid paying up to a $615 deductible in 2026 up front and fill your prescriptions on time.
Out-of-network care
If you’re enrolled in a Medicare Advantage plan, you will have a network that includes doctors and healthcare professionals as well as hospitals and other facilities that are covered under your plan. Your care is limited to this network, or you will pay higher out-of-pocket charges. When shopping for a Medicare Advantage plan, make sure the healthcare professionals and facilities you use most often are in the network of any plan you’re considering.
Healthcare professionals and facilities can be dropped or added to a plan’s network throughout the year. So it’s always a good idea to double-check that a doctor or hospital you’re planning to visit is still in your plan’s network in order to prevent unwelcome surprise bills.
Some Medicare Advantage plans require approval, known as prior authorization, before covering certain services, items, or medications. (You have a separate prior approval process for prescription coverage.) If you have an existing Medicare Advantage plan, it’s important to review the Annual Notice of Change (ANOC) sent by your plan in the fall. This document will tell you what changes to expect in the next coverage year, so you can decide if the Medicare Advantage plan still fits your needs.
More frequent coverage denials
Some Medicare beneficiaries don’t realize they can appeal a payment or coverage decision. If you disagree with a decision from your Medicare Advantage plan, you have the right to dispute it. The appeals process can be time-consuming, but with persistence and good record-keeping, most decisions are partially or fully overturned.
You have the right to appeal decisions involving:
A request for a healthcare service, item, supply, or prescription medication you believe you are eligible to receive
A request for payment of a healthcare service, item, supply, or prescription medication that you already received
A request to change the amount you must pay for a healthcare service, item, supply, or prescription medication
A situation in which your Medicare Advantage plan stops providing or paying for all or part of a healthcare service, item, supply, or prescription medication you determine you still need
If you decide to appeal a decision, ask your healthcare provider for information that can help your case.
Medicare Advantage plans aren’t perfect. A 2022 federal analysis of Medicare Advantage appeals by providers and enrollees found that nearly 1 in 5 payment denials were for claims that met Medicare coverage rules. The most common healthcare services that won appeals included:
Advanced imaging services, such as MRIs and CT scans
Stays in post-acute facilities, such as inpatient rehabilitation facilities
Pain management injections
In 2024, Medicare Advantage plan insurers fully or partially denied 4.1 million prior authorization requests. That means about 7.7% of the nearly 53 million Medicare Advantage prior authorization reviews were turned down.
Medicare Advantage enrollees rarely fight denials — even though most are at least partially successful. In 2024, roughly 11.5% of denials were appealed. CMS found that about 81% of those appeals were fully or partially overturned. Still, care was delayed.
The bottom line
Medicare Advantage plans can be tricky to navigate. Finding the best one for your needs requires shopping around.
To avoid costly missteps, pay attention to plan details such as out-of-pocket limits, zero-premium options, and extra benefits. If you don’t choose a plan that includes prescription coverage, you may need to buy a separate Part D plan that covers your medications.
Once you have a Medicare Advantage plan, remember to go to healthcare providers in your network and take action by filing an appeal if a claim is denied.
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References
Biniek, J. F., et al. (2026). Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024. KFF.
Centers for Medicare & Medicaid Services. (2025). Final CY 2026 Part D redesign program instructions.
Centers for Medicare & Medicaid Services. (2025). Medicare Advantage and Medicare prescription drug programs expected to remain stable in 2026.
Data.CMS.gov. (2025). Medicare enrollment dashboard.
Medicare.gov. (n.d.). Explore your Medicare coverage options.
Medicare.gov. (n.d.). Filing an appeal.
Medicare.gov. (n.d.). What original Medicare covers.
Medicare.gov. (2025). Understanding your Medicare Advantage Plan’s provider network.
Ochieng, N. (2025). Medicare Advantage in 2025: Premiums, out-of-pocket limits, supplemental benefits, and prior authorization. KFF.
U.S. Department of Health and Human Services Office of Inspector General. (2022). Some Medicare Advantage organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care.
