This is general information, not insurance, medical, legal, or financial advice. Plan rules, prices, and protections differ by country, state, insurer, and employer, so the documents for your own plans always take priority over anything written here.
A plan comparison is easiest when you stop trying to find the “best” plan and instead ask which plan fits your expected use of care, your budget, and your tolerance for risk. The method below works for comparing an employer plan with a marketplace plan, two employer options, or your renewal against a competing offer.
Start with your own year, not the plan
Before you open any plan documents, write down what you actually used over the past year or two, and what you expect next year.
- Regular doctors, specialists, and any facility you rely on
- Prescriptions, including the exact names and doses
- Planned events such as surgery, pregnancy, therapy, or imaging
- Who needs to be covered, and whether anyone’s situation is changing
Your claim history and past explanation of benefits statements are a good source. Remember that the past is only a guide: a quiet year does not guarantee another one, and a plan should still protect you if something unexpected happens.
Build a side-by-side worksheet
Make one column for your current plan and one for each alternative. Use the plan’s summary document (often called a summary of benefits and coverage or, at work, a benefits summary) so that each plan is described in the same format. Fill in the following rows.
| Row | What to record |
|---|---|
| Monthly premium | What you pay, after any employer or subsidy help |
| Deductible | Individual and family amounts |
| Out-of-pocket limit | The most you could pay in a year for covered care |
| Copays and coinsurance | For primary visits, specialists, urgent care, emergency care |
| Network type | HMO, PPO, EPO, or another design |
| Referral rules | Whether you need approval to see specialists |
| Drug coverage | Each of your medications and its tier |
| Extra accounts | Whether an HSA, FSA, or HRA is available |
If the documents do not answer something, call the insurer or the benefits department and note what they tell you, with the date.
Look at total cost, not only the premium
The premium is the one cost you pay for certain, so it draws attention. But the deductible, coinsurance, and out-of-pocket limit decide what you pay when you use care. A useful habit is to calculate two totals for each plan: a best case and a worst case. The details behind these terms are covered in our look at premiums and costs and in the explanation of the out-of-pocket maximum.
Here is a hypothetical example with invented numbers, only to show the arithmetic.
- Plan A: premium of $300 per month and an out-of-pocket limit of $4,000.
- Plan B: premium of $200 per month and an out-of-pocket limit of $8,000.
Yearly premiums are $3,600 for Plan A ($300 x 12) and $2,400 for Plan B ($200 x 12). In a year with almost no care, Plan A costs about $3,600 and Plan B about $2,400, so Plan B looks cheaper. In a bad year where you reach the limit, Plan A costs at most $3,600 + $4,000 = $7,600, while Plan B costs at most $2,400 + $8,000 = $10,400. The gap works in the other direction. Which plan is better depends on how likely you are to need care, and on whether you could comfortably pay the larger limit if you had to. Costs for out-of-network care or uncovered services can come on top of these totals.
Check the network against your real providers
A cheaper plan is not a saving if your doctor is not in it. Look up each provider and facility you use in the plan’s current directory, then confirm by phone with the provider’s office, since directories can be out of date. Our overview of provider networks explains why network design matters, and the page on out-of-network care shows what can happen to your bill if a provider is outside the plan. If you expect to see specialists, check whether the plan requires specialist referrals, and compare the differences in HMO versus PPO designs.
Check prescriptions and approval rules
Search the plan’s drug list for every medication you take. Note the tier, any quantity limits, and whether the plan uses prior authorization or step therapy for any of them. For people who depend on a particular drug, medication-driven plan choice can matter more than any other factor. A drug that is covered on one plan and excluded on another can change the yearly total sharply.
Consider money you get from the employer or the government
For a workplace plan, the employer contribution may make a plan with a higher sticker price cheaper for you. For marketplace coverage, premium subsidies and cost-sharing reductions may change the real price, but eligibility and amounts depend on your location and circumstances, so check with the official marketplace for your area. Do not compare a plan’s full price with another plan’s price after help; compare what you would actually pay.
Do not forget timing and transitions
Switching plans is not always free of side effects. Money you have already spent toward a deductible may not carry over, as covered in our article on mid-year switching. Waiting periods may apply, and a new plan may start later than the old one ends, which creates coverage gaps. Check the coverage effective date of the new plan and the end date of the current one.
Read the fine print
Last, scan the policy documents for exclusions, annual limits on specific services such as therapy or equipment, and rules about care away from home. A few minutes here can catch the surprises that a summary table hides.
Make the decision and keep a record
Rank what matters most to you, perhaps keeping your doctor, a predictable budget, or low drug costs, and see which plan wins on those points. Save the worksheet, the date of any phone calls, and the names of people you spoke to. If a plan later turns out to differ from what you were told, that record is useful. If your situation is complicated, a licensed professional or a free counseling service in your area can help you check your reasoning.