Most people choose a Medicare plan during the Annual Enrollment Period (AEP) in the fall, set it up, and then move on with their lives. That is understandable — once you have made your decision and your coverage kicks in on January 1, it is natural to assume everything will stay the same for the rest of the year. But Medicare plans are not static. Formularies can change, providers may leave networks, your health needs may shift, and out-of-pocket costs may not land where you expected. A mid-year review of your Medicare coverage can help you catch problems early, take advantage of options you may not know about, and prepare for the next enrollment season with a clear picture of what is and is not working.
Here is a practical guide to conducting your own mid-year Medicare checkup.
Why Review Your Coverage Mid-Year?
There are several reasons your Medicare plan experience in June or July may look different from what you expected in January:
- Formulary changes. With CMS approval, plans may adjust their drug formularies during the plan year. A medication you rely on could be moved to a different tier or subjected to new coverage requirements.
- Network changes. Doctors, specialists, and facilities can leave a plan's provider network at various points throughout the year. If your preferred provider is no longer in-network, you may face higher costs or need to find a new one.
- Changes in your health. A new diagnosis, an upcoming surgery, or the start of ongoing treatment may mean your current plan no longer fits your needs as well as it did when you enrolled.
- Cost surprises. Your actual out-of-pocket spending may be tracking differently than you anticipated — higher deductible charges, unexpected copays, or changes to your monthly payment plan amount.
A mid-year check does not require you to make any immediate changes. It simply helps you understand where you stand and whether any action may be appropriate — now or during the next AEP. For a full overview of how the AEP works, see our guide to the Medicare Annual Enrollment Period.
Check Your Formulary for Drug Coverage Changes
One of the most impactful mid-year changes involves your plan's formulary — the list of prescription drugs your plan covers and the cost-sharing tier each drug falls under. While plans cannot remove a drug from the formulary entirely without following CMS rules, they may make other adjustments during the year, including:
- Moving a drug to a higher cost-sharing tier, which increases what you pay at the pharmacy
- Adding prior authorization requirements, meaning your doctor must get plan approval before the drug is covered
- Requiring step therapy, which means you may need to try a lower-cost drug first before your plan covers the one your doctor originally prescribed
If any of these changes affect a medication you are currently taking, your plan is generally required to notify you in advance. However, it is still a good idea to proactively check. You can do this by:
- Visiting your plan's website and searching the current formulary
- Calling your plan's member services number (on the back of your plan card)
- Reviewing any notices or letters your plan has sent — these are easy to overlook
If a drug you depend on has been moved to a higher tier or is no longer covered under the same terms, you have the right to request a formulary exception from your plan. This is a formal process in which your doctor can provide supporting documentation explaining why the specific medication is medically necessary for you. For more details on how formularies work, see our guide to how Medicare Part D formulary tiers and coverage work.
Verify Your Provider Network
Even if you confirmed your doctors were in-network when you enrolled, that can change. Providers may leave a plan's network at various points during the year due to contract changes or other reasons. If you are enrolled in a Medicare Advantage (MA) plan — particularly an HMO — using out-of-network providers generally means paying significantly more or having no coverage at all for those services.
Here is what to check:
- Visit your plan's online provider directory. These directories are updated regularly and reflect current network status. Search for your primary care doctor, any specialists you see, and any facilities (hospitals, labs, imaging centers) you use.
- Call the provider's office directly. If you want to confirm, a quick call to your doctor's billing department can verify whether they are still contracted with your plan.
- Check for continuity of care protections. If your doctor has left the network and you are in the middle of active treatment — such as chemotherapy, post-surgical recovery, or management of a complex condition — most plans are required to offer continuity of care protections. This generally means temporary access to that out-of-network provider while you transition to an in-network alternative.
If you find that key providers are no longer in your plan's network, make note of it. This may factor into your plan choice during the next AEP, or it may qualify you for a Special Enrollment Period depending on the circumstances.
Review Your Out-of-Pocket Spending
Mid-year is a good time to check how much you have spent so far and how that compares to what you expected. This helps you anticipate what the rest of the year may look like financially.
Start by reviewing your Explanation of Benefits (EOB) statements or logging into your plan's online member portal. Look at:
- How much you have spent toward your deductible. Have you met it? Are you close? This affects your cost-sharing for the remainder of the year.
- How much you have spent toward your Maximum Out-of-Pocket (MOOP) limit. Medicare Advantage plans have a MOOP cap, and once you reach it, your plan covers 100% of covered services for the rest of the year. Knowing where you stand helps you plan for upcoming care.
- Your prescription drug spending. If you are enrolled in the Medicare Prescription Payment Plan, check whether your monthly installment amount has changed. Plans recalculate these amounts when your prescriptions or costs change. For a detailed explanation of how the payment plan works, see our guide to the Medicare Prescription Payment Plan.
Tracking your spending mid-year can reveal whether your current plan is performing as expected or whether costs are running higher than anticipated — information that is valuable when evaluating plans during the next enrollment period.
Has Your Health Changed?
Life does not wait for enrollment periods. If your health situation has shifted since you chose your plan, it is worth evaluating whether your current coverage still fits:
- New diagnosis. A diagnosis of a chronic condition like diabetes, heart disease, or COPD may require ongoing specialist care, additional prescriptions, or medical equipment. Your current plan may or may not offer strong coverage for these needs.
- Upcoming or recent surgery. If you are facing a procedure, check whether the surgeon and facility are in-network and what your plan's cost-sharing looks like for inpatient and outpatient services.
- Specialist network gaps. If you now need to see a specialist — such as a cardiologist, oncologist, or neurologist — verify that your plan's network includes providers in that specialty near you.
- Special Supplemental Benefits for the Chronically Ill (SSBCI). Some Medicare Advantage plans offer SSBCI benefits for enrollees who have been diagnosed with certain chronic conditions. These may include coverage for things like meals, transportation, pest control services, or home modifications — benefits that go beyond what standard MA plans typically offer. Not every plan offers SSBCI, and eligibility requirements vary, so check with your plan or review the plan's Evidence of Coverage document.
Even if you cannot switch plans right now, understanding how your current plan handles your new health needs helps you make a more informed choice during the next AEP.
Special Enrollment Periods You May Qualify For
Many people assume they can only change their Medicare plan during the AEP in the fall. But there are several Special Enrollment Periods (SEPs) that may allow you to make a change outside of that window. Some of the most common include:
- You moved to a new service area. If you relocated to an area where your current plan is not available, you generally qualify for a SEP to choose a new plan.
- You lost other health coverage. If you lost employer-sponsored coverage, COBRA, or Medicaid, you may be eligible for a SEP.
- Your plan violated its contract. If your plan failed to provide medically necessary services or misled you about its coverage, CMS may grant you a SEP.
- You entered or left a nursing facility. This triggers a SEP that allows you to make plan changes.
- You qualify for Extra Help (Low-Income Subsidy). Beneficiaries who receive Extra Help can switch Part D plans once per quarter during the first three quarters of the year.
- 5-star plan enrollment. If a Medicare Advantage or Part D plan in your area has a 5-star overall quality rating, you may enroll in it once per year at any time outside of AEP. For more on what star ratings mean and how they are measured, see our guide to understanding Medicare Star Ratings.
This is not an exhaustive list. For a complete overview of all available SEPs and when they apply, see our detailed guide to Medicare Special Enrollment Periods.
The Medicare Advantage Open Enrollment Period (January 1 – March 31)
If you are reading this during the first quarter of the year, you may still be within the Medicare Advantage Open Enrollment Period (MA OEP). This runs from January 1 through March 31 each year and is available to anyone currently enrolled in a Medicare Advantage plan.
During the MA OEP, you are allowed to make one plan change:
- Switch from one MA plan to another MA plan
- Drop your MA plan and return to Original Medicare, with the option to enroll in a standalone Part D prescription drug plan and, depending on your situation, apply for a Medigap policy
The MA OEP is not available to people enrolled in Original Medicare who want to join an MA plan — it is specifically for current MA enrollees who want to make an adjustment after their AEP choice has taken effect.
Prepare for the Next Annual Enrollment Period
Even if you determine that your current plan is working well for now, your mid-year review is an opportunity to prepare for the next AEP (October 15 – December 7). Rather than starting from scratch in the fall, consider keeping a running list of observations throughout the year:
- Provider issues. Did any of your doctors leave the network? Was it difficult to get referrals or specialist appointments?
- Drug coverage concerns. Were any of your medications moved to a higher tier or subjected to new restrictions? Did you experience any delays related to prior authorization?
- Cost surprises. Were your copays, coinsurance, or deductible charges higher than expected? Did your total out-of-pocket spending exceed what you budgeted?
- Benefits you did not use. Does your plan include benefits — like dental, vision, hearing, fitness, or over-the-counter allowances — that you are not using? Would a different plan offer benefits better suited to your needs?
- Service quality. Were you satisfied with your plan's customer service? Were claims processed accurately and in a timely manner?
In late September, your plan will send you an Annual Notice of Change (ANOC), which outlines any changes to your plan's benefits, costs, formulary, or network for the upcoming year. If you have been tracking your concerns throughout the year, you will be well positioned to compare your current plan against alternatives when the AEP opens.
Taking Action
A mid-year Medicare checkup does not need to be complicated. Here is a simple action list to get started:
- Log into your plan's member portal or call member services to review your current formulary, provider directory, and out-of-pocket spending.
- Review any notices your plan has mailed you — especially formulary change letters or network update notifications.
- Check whether you qualify for a Special Enrollment Period if your circumstances have changed.
- Start a list of anything that is not working well with your current plan. Keep it somewhere accessible so you can reference it during the next AEP.
- Use free resources. You can visit Medicare.gov to compare plans, call 1-800-MEDICARE (1-800-633-4227) for assistance, or contact your local State Health Insurance Assistance Program (SHIP) for free, unbiased counseling from a trained volunteer. SHIP counselors can help you understand your options and are available year-round — not just during enrollment periods.
Your Medicare coverage is one of the most important financial and health decisions you manage each year. Taking a few minutes mid-year to review how your plan is performing can help you avoid surprises, catch problems early, and make more confident decisions when the next enrollment window opens.