For Consumers

Questions to ask when comparing health plans

What does the plan pay for and what does it exclude?

Most health plans must include a standard set of benefits, also known as essential health benefits ( They include services, such as maternity and newborn care, preventive services and prescription drug coverage. In addition, most plans cannot require pre-existing condition waiting periods.

Find out how the plan works


  • Do you have coinsurance or a copay, and if so, how much is it?
  • How much is the deductible?
  • How often will you have to pay out-of-pocket for copays or deductibles?
  • Are there limits on the number of times you can receive a service (lifetime maximums, daily, or annual benefit caps)?
  • Are your prescriptions on the list of covered drugs (also called the "formulary")?
  • Are some or all of your medical providers in the plan's network?

Find out if there are special requirements to get your care covered

For example:

  • Do you need prior authorization for some services? If so, how do you get authorization?
  • Does the plan exclude coverage for some types of care?

To help you compare plans, use our health plan comparison form (PDF, 90.33 KB).