Learning center · Choosing your coverage
How to Check Your Doctors and Drugs in a Plan
The most expensive Medicare surprises show up at the clinic desk or the pharmacy counter in January. Most of them can be caught in an afternoon in October.
The short answer
Before choosing a Medicare plan, check two lists: the plan's provider network and its formulary, the list of covered drugs. Enter every prescription, with its exact dose and how often you take it, into Medicare Plan Finder at Medicare.gov, choose your usual pharmacy, and compare the estimated yearly drug cost, not just the premium. Then confirm each doctor, clinic and hospital you use is in the plan's network by checking the plan's own directory and calling the office to ask whether they take that specific plan. Do this every fall during Open Enrollment, October 15 to December 7, because networks and drug lists can change each year. With Original Medicare, any provider that takes Medicare will see you; only the drug plan needs checking.
- Plan Finder estimates your yearly drug cost by plan; compare that total, not the premium alone.
- Check each drug's tier and any prior authorization, step therapy or quantity limit.
- Confirm doctors in two places: the plan's directory and a phone call to the office about that exact plan.
- Plans mail the Annual Notice of Change by September 30; read the network and drug sections first.
- For 2027 the Part D deductible can be no more than $700 and out-of-pocket drug costs are capped at $2,400.
Why this check matters more than the premium
Two terms carry most of the risk. A network is the group of doctors, hospitals and other providers a plan contracts with. Medicare Advantage plans usually require you to use their network for non-emergency care, according to Medicare.gov, and some plans pay nothing out of network. A formulary is a plan's list of covered drugs, sorted into tiers that set what you pay.
A plan with a low premium can cost far more in a year if it puts one of your drugs on a high tier or leaves out the clinic you use. Around Sioux Falls, many people get their care through one of the two large health systems, Sanford Health or Avera, and networks do not always include both. Our newsroom article on Sanford and Avera Medicare networks goes into the local picture.
Step by step: checking your drugs
- Make a complete list. Every prescription, with the exact name, strength, form (tablet, injection, inhaler) and how many you take a month. Include anything you fill by mail.
- Open Medicare Plan Finder. You can use it without logging in, though logging in lets you save a drug list. Enter your ZIP code and choose the plan type.
- Enter each drug and your pharmacy. Choose the pharmacy you actually use. Prices can differ between preferred and standard pharmacies in the same plan.
- Sort by estimated total yearly drug and premium cost. This combines premiums, the deductible and your copays across the year.
- Open the plans near the top and read the drug details. Look at the tier for each drug, and whether it carries prior authorization (the plan must approve it first), step therapy (you try a different drug first) or a quantity limit.
- Note anything not covered. A drug missing from the formulary is the most expensive surprise of all. Plans have an exceptions process, but it is better to choose a plan that covers it.
For 2027, Medicare.gov's drug costs page sets the most a plan's Part D deductible can be at $700, and caps what you pay out of pocket for covered drugs at $2,400 for the year. After that, you pay $0 for covered drugs for the rest of 2027. The cap does not include premiums.
Would you like a second pair of eyes on your drug list?
Most people do this part on their own and then want someone to check it. We run your list against the plans we offer and flag tiers, limits and anything not covered.
Book a conversation →Step by step: checking your doctors and hospitals
- List everyone you see. Primary care, specialists, the hospital you would want to go to, therapists, and any clinic you visit regularly. Note the clinic location as well as the doctor's name, because a doctor can be in network at one location and not another.
- Check the plan's provider directory. Plan Finder links to each plan's directory. Search by the doctor's name and location.
- Look up details on Care Compare. Medicare's tool lists doctors, hospitals and other providers who take Medicare and shows quality information.
- Call the office. Ask the billing staff whether they are in network for the exact plan name for 2027, not just the insurance company. Write down who you spoke with and the date.
- Check referrals and prior authorization. Ask the plan whether you need a referral to see your specialists.
If you split your year between South Dakota and somewhere warmer, check how each plan handles care away from home. Our snowbird coverage article covers the questions to ask.
Do it again every fall
Networks and drug lists can change each January. The CMS Medicare & You 2027 handbook says your plan sends an Annual Notice of Change (ANOC) by September 30, describing changes for the next year, and makes its Evidence of Coverage available by October 15. Read the drug list and network sections first.
| When | What happens |
|---|---|
| By September 30 | Your plan sends its Annual Notice of Change for the coming year |
| By October 15 | Your plan makes its Evidence of Coverage available |
| October 15 to December 7 | Open Enrollment: anyone can change health or drug plans; changes start January 1 |
| January 1 to March 31 | Medicare Advantage Open Enrollment: people in Medicare Advantage can make one change |
Source: CMS, Medicare & You 2027 handbook; Medicare.gov, Joining a health or drug plan. Dates apply each year; 2026 Open Enrollment sets 2027 coverage.
The handbook also says plans must tell you if a primary care or behavioral health provider you have seen in the past three years leaves the network. If you get that letter, it is a good reason to recheck everything.
One more limit to check: Medicare Advantage plans must cap what you pay for covered services in network each year. For 2027 the cap can be no higher than $9,850 under the CMS 2027 standards. Compare each plan's actual cap, not just its premium.
Where Big Sioux Benefits fits
Everything above can be done on your own, and Medicare.gov's tools are built for it. What we add is time and practice: we run your drug list and providers against the plans we offer, call offices when a directory is unclear, and explain trade-offs between a plan's premium, its yearly cap and your actual prescriptions. Our drug cost review and plan comparison pages describe how that works.
Questions, answered
How do I check if my drugs are covered by a Medicare plan?
Enter each prescription, with its dose and quantity, and your pharmacy into Medicare Plan Finder at Medicare.gov. Then open each plan to see the tier and any prior authorization, step therapy or quantity limits for each drug.
How do I check if my doctor is in a Medicare Advantage network?
Search the plan's provider directory for the doctor and clinic location, then call the office and ask whether they are in network for that exact plan for the coming year.
What is a formulary?
A plan's list of covered prescription drugs. Drugs are sorted into tiers, and the tier sets what you pay. A formulary can change from one year to the next.
Do I need to check doctors with Original Medicare?
Not for networks. Medicare.gov says that with Original Medicare you can use any doctor or hospital that takes Medicare, anywhere in the U.S. You still need to check drugs in any Part D plan you add.
What is the Part D out-of-pocket cap for 2027?
Medicare.gov lists a $2,400 cap on what you pay out of pocket for covered drugs in 2027, with a maximum deductible of $700. Premiums do not count toward the cap.
When should I recheck my plan?
Every fall. Plans send an Annual Notice of Change by September 30, and Open Enrollment runs October 15 to December 7, with changes starting January 1.
What if my doctor leaves my plan's network?
The CMS Medicare & You 2027 handbook says plans must notify you when a primary care or behavioral health provider you have seen in the past three years leaves. Depending on your situation, you may be able to change plans during an enrollment period.
Figures and sources
Every figure on this page, where it comes from, and the period it covers. Checked October 19, 2026.
| Figure | Source | Period |
|---|---|---|
| Annual Notice of Change sent by September 30; Evidence of Coverage available by October 15 | CMS, Medicare & You 2027 handbook | 2027 plan year |
| Notice required when a primary care or behavioral health provider seen in the past three years leaves the network | CMS, Medicare & You 2027 handbook | 2027 handbook |
| Open Enrollment October 15 to December 7; Medicare Advantage Open Enrollment January 1 to March 31 | Medicare.gov, Joining a health or drug plan | October 15 to December 7, 2026 for 2027 coverage |
| Medicare Advantage in-network out-of-pocket ceiling $9,850 | CMS, Final CY2027 Part C Bid Review Standards (April 22, 2026) | 2027 plan year |
| Part D maximum deductible $700; out-of-pocket cap $2,400, then $0 for covered drugs | Medicare.gov, Costs for Medicare drug coverage | 2027 plan year |
| Original Medicare: any provider that takes Medicare; Medicare Advantage: may need network providers for non-emergency care | Medicare.gov, Compare Original Medicare & Medicare Advantage | Current, checked October 19, 2026 |
Official sources
- Medicare.gov: Medicare Plan Finder
- Medicare.gov: Care Compare
- CMS: Medicare & You 2027 handbook
- Medicare.gov: Joining a health or drug plan
- Medicare.gov: Costs for Medicare drug coverage
- Medicare.gov: Compare Original Medicare & Medicare Advantage
- CMS: Final CY2027 Part C Bid Review Standards
How this guide is made: the Big Sioux Benefits Data Desk writes from official sources and checks each figure against the page it cites. This is general education, not advice about your situation. Plan details vary; confirm costs and coverage with Medicare.gov, the agency named above, or a licensed agent.
- Provider and plan finder tool Search plans by ZIP code on this site.
- Using Medicare Plan Finder in Sioux Falls Our newsroom walk-through.
- Part D formulary tiers explained
- Reading your 2027 Annual Notice of Change
- Plan comparison How Big Sioux Benefits can help.
- Medicare Advantage plans How Big Sioux Benefits can help.
- Medicare Supplement plans How Big Sioux Benefits can help.
- All guides in the learning center