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Where plans may differ and how to weigh differences

  • Provider network: Most plans must meet standards for ease of getting to the doctor or hospital you need (known as network adequacy). But plans may vary quite a bit on how they meet this standard and their quality. If you have providers you want to continue to see with your marketplace plan, you can check the provider directory to see if they are included in the plan’s network. You may also want to call your providers and check with them, since provider directories can be out-of-date.
  • Formulary: All plans must meet standards for how and what prescription drugs are covered, but they may vary on how they meet this standard. If you have prescriptions you expect you’ll need, you can check the formulary for the plans you are considering. The formulary is a list of prescription drugs that will be covered by the plan. In some cases, you may need to get prior approval or meet some other rules to get your drug covered by the plan, so be sure to check your plan’s rules.
  • Deductible: Plans can vary by how much you may have to pay out-of-pocket before your coverage starts. This is known as the deductible, and this can be the case even for plans in the same metal level. Some services may be covered before the deductible is met – for example, a minimum number of primary-care doctor visits and recommended preventive services.
  • Dental/vision coverage: Pediatric services, including vision and dental benefits, are required to be covered as part of the essential health benefits. But plans don’t have to cover vision and dental services for adults, and in both cases, the coverage for these services may be offered as a separate plan. If these services are important for you or your children, be sure to check if they are included in your plan or if you must buy a separate plan to get coverage for them.