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Ten concrete things to check before you pick a plan, each one worth a few minutes and able to save you hundreds.
The short version
Before picking a health insurance plan during open enrollment, confirm your doctors and prescriptions are covered, calculate your total expected annual cost rather than just the premium, understand your deductible and out-of-pocket maximum, check your subsidy eligibility, and know your exact enrollment deadline. Working through these 10 items in order takes most people under an hour and prevents the two most common and expensive mistakes: picking a plan that excludes a doctor or medication you actually need, and underestimating what a "cheap" plan will really cost you over a full year.
Open enrollment moves fast, and most of the mistakes people make happen for the same reason: they compare plans by premium alone and sort out the rest later. Here are 10 concrete things worth checking before you actually pick a plan this year.
Confirm your doctors and hospitals are actually in-network
Before you look at a single premium, check whether your current doctors, specialists, and preferred hospital are in-network under each plan you're considering. Insurance networks change every year, and a plan that covered your doctor last year isn't guaranteed to this year. Search each plan's current provider directory directly rather than trusting a general "broad network" label, and consider calling your doctor's office to confirm they're still accepting that specific plan.
Check your prescription drug formulary
If you take regular medications, look up each plan's specific formulary and confirm which cost tier your prescriptions fall into. The same drug can be a low-cost generic tier under one plan and a much higher specialty tier under another, and formularies change annually even within the same plan. This is one of the easiest things to overlook and one of the most expensive to get wrong.
Calculate your total expected annual cost, not just the premium
A low monthly premium often pairs with a high deductible and higher cost-sharing once you actually need care. Add your expected annual premium to a realistic estimate of your deductible, copay, and coinsurance costs based on how much healthcare you actually use, rather than comparing the premium number alone. This single step is what separates people who save money from people who just think they saved money.
Understand your deductible and when it resets
Know exactly what your deductible is, whether it applies to all services or only certain categories, and when it resets, since most plans reset on a calendar-year or plan-year basis. If you're switching plans mid-year, remember that your new plan's deductible generally starts over from $0, even if you've already paid toward your old plan's deductible this year.
Compare the out-of-pocket maximum specifically
Your out-of-pocket maximum is the real ceiling on your financial risk in a bad year, the point past which your plan covers 100% of covered costs. Compare this number directly between plans, not just the premium or deductible individually, especially if you have any reason to expect a major medical event in the coming year.
Check your subsidy and cost-sharing reduction eligibility
If you're shopping on the ACA Marketplace, check your current subsidy eligibility based on your projected income for the coverage year, not last year's tax return. If your income falls at or below 250% of the federal poverty level, also check whether a Silver plan would unlock cost-sharing reductions, which lower your deductible and copays on top of your reduced premium, a benefit that's easy to miss if you default to a cheaper Bronze plan.
Decide between HMO, PPO, EPO, and other network types
Understand what type of network each plan uses, since this affects your flexibility, not just your cost. An HMO typically requires a primary care referral to see specialists and only covers in-network care except in emergencies. A PPO offers more flexibility to see out-of-network providers, usually at a higher cost. An EPO sits in between, generally requiring in-network care but without a referral requirement. Pick the structure that matches how you actually want to access care, not just the one with the lowest premium.
Review the plan's specific exclusions and coverage gaps
Read through what each plan specifically excludes, not just what it covers. Common exclusions worth checking include cosmetic procedures, certain fertility treatments, out-of-country coverage, and specific therapies or durable medical equipment. If you have a known upcoming need, confirm directly that it's covered rather than assuming a standard plan automatically includes it.
Check whether your preferred pharmacy is in-network
Beyond the formulary itself, confirm that your usual pharmacy, or a pharmacy that's actually convenient for you, is in-network under the plan's specific pharmacy network. Some plans use a narrower pharmacy network than their medical provider network, and filling a prescription out-of-network can cost significantly more even for a covered medication.
Confirm your exact enrollment deadline
Know your specific enrollment deadline, whether that's the ACA Marketplace's open enrollment window, your employer's enrollment period, or Medicare's annual enrollment period, and don't wait until the final days to act. Missing your window generally means waiting for the next one, unless you qualify for a Special Enrollment Period due to a specific qualifying life event. Confirming your exact deadline early gives you time to actually work through items 1 through 9 properly, rather than rushing through them at the last minute.
Consider two plans with a similar-looking price difference: Plan A costs $320 a month with a $6,000 deductible, while Plan B costs $410 a month with a $2,000 deductible. On premium alone, Plan A looks like the better deal, saving $1,080 a year. But if you expect even one meaningful medical event, say a $4,000 procedure, Plan B's lower deductible means you'd pay substantially less out-of-pocket for that same year once the deductible difference is factored in. Neither plan is universally "better," but working through items 1 through 5 on this checklist is what actually reveals which one fits your specific situation, rather than the premium alone misleading you in either direction.
How an Apollo Insurance agent can help you choose the best plan
Working through a 10-item checklist on your own is doable, but a licensed Apollo Insurance agent can do most of this legwork for you and catch things a self-guided comparison might miss. Specifically, an agent can:
Check your network and formularyAgainst each available plan's actual network and formulary, rather than you cross-referencing multiple provider directories yourself.
Calculate your realistic total costAcross several plans side by side, using your actual expected healthcare usage rather than a generic estimate.
Confirm your subsidy eligibility preciselyBased on your real projected income and household size.
Explain HMO vs. PPO vs. EPO in practical termsIn the context of your specific preferred providers, not just in the abstract.
Flag exclusions relevant to your needsAny known upcoming medical need you've mentioned, checked against the plan's actual exclusions.
Confirm your exact deadlineAnd make sure your application is submitted correctly and on time.
Because licensed agents are compensated by the insurance carriers rather than by charging clients directly, getting this kind of detailed, personalized help costs you nothing beyond what you'd pay enrolling on your own.
The full checklist, at a glance
- Confirm your doctors and hospitals are in-network.
- Check your prescription drug formulary.
- Calculate your total expected annual cost, not just the premium.
- Understand your deductible and when it resets.
- Compare the out-of-pocket maximum specifically.
- Check your subsidy and cost-sharing reduction eligibility.
- Decide between HMO, PPO, EPO, and other network types.
- Review the plan's specific exclusions and coverage gaps.
- Check whether your preferred pharmacy is in-network.
- Confirm your exact enrollment deadline.
For the authoritative, non-commercial sources on this topic, HealthCare.gov publishes official plan comparison tools and current enrollment deadlines directly, and the National Association of Insurance Commissioners (NAIC) publishes consumer guidance on comparing health insurance plan types and cost-sharing structures.
Frequently asked questions about choosing a health insurance plan
Have a question that isn't answered below? Our full health insurance FAQ page covers more, and our blog has deeper guides on specific coverage topics.
What's the most important thing to check before picking a health insurance plan?
Is a lower premium always a better deal?
What's the difference between a deductible and an out-of-pocket maximum?
How do I know if I qualify for a subsidy or cost-sharing reduction?
What happens if I miss my enrollment deadline?
Does it cost more to use an Apollo agent to help me choose a plan?
Ten items sounds like a lot until you realize most of them take just a few minutes once you have your current doctors, prescriptions, and rough budget in front of you. Working through this list in order, rather than jumping straight to the premium, is what actually protects your coverage and your budget for the year ahead. If your situation includes a short gap to bridge, it's also worth comparing a short-term plan or family coverage options alongside a standard Marketplace plan.
Need help working through your health insurance checklist? We're here to help. At no cost.
A licensed Apollo agent can check your specific doctors, prescriptions, and subsidy eligibility, and help you compare plans side by side before your enrollment deadline closes.
Explore ACA Marketplace plans, individual coverage, or learn more about our licensed advisors.
Disclaimer: This checklist is general educational information about choosing a health insurance plan and is not insurance, tax, or legal advice. Plan details, subsidy eligibility, and enrollment deadlines vary by state, employer, and individual circumstances. Verify current details with HealthCare.gov, your plan administrator, or a licensed Apollo Health Insurance agent before making a coverage decision. Apollo Health Insurance is a licensed insurance brokerage; we are not affiliated with the federal government or any state agency.
I am a professional content writer specializing in the health insurance field. My work primarily focuses on simplifying the complexities of healthcare coverage, aiming to provide clarity and insight into an often confusing subject. Empowering people to make informed decisions about their well-being is my passion. At Apollo Health Insurance, we share that commitment. Apollo Health Insurance stands at the forefront of securing the best healthcare coverage for individuals, ensuring affordability without compromising on quality.