Guides to using your coverage well.

Most people pick a plan by scanning monthly premiums, which is the one number that says the least about what a year of coverage will cost. Work through these five steps in order instead.

1. Write down the care you used last year

Count office visits, specialists, therapy sessions, imaging, procedures, and every prescription you refill. Next year is rarely identical, but last year is the best estimate you have, and it turns an abstract comparison into arithmetic.

2. Check that your doctors are in network

Networks are set per plan, not per insurer, so the same company can sell one plan your doctor accepts and another they do not. Look up each provider in the plan directory, then call the office and confirm they take that exact plan for the coming year.

3. Check that your drugs are on the formulary

Search each medication on the plan drug list and note the tier it lands on, whether prior authorization or step therapy applies, and whether a preferred pharmacy is required. A plan that leaves one of your maintenance drugs off the list can cost more than a higher premium would have.

4. Compare total cost, not premium

For each plan, add twelve months of premium to the care you expect to pay for before the plan starts paying. Then look at the out-of-pocket maximum, which is the worst case if the year goes badly. A plan with a higher premium and a much lower maximum can be the cheaper choice for someone who uses a lot of care.

5. Check what help you qualify for

If you buy your own coverage, a premium tax credit may lower your monthly cost, and cost-sharing reductions can lower your deductible and copays if your income qualifies and you choose a Silver plan. Eligibility depends on income, household size, and where you live, so the only reliable answer comes from checking plans for your own address.

Related: how marketplace plans and metal tiers work.

Your premium is what you pay every month to keep the plan, whether or not you see a doctor. It does not count toward anything else on this list.

Your deductible is the amount you pay for covered services before the plan starts sharing the cost. Preventive care and, on many plans, some office visits and generic drugs are covered before you meet it.

A copay is a flat amount for a specific service, such as a set dollar amount per office visit. Coinsurance is a percentage of the cost instead, and it usually starts after the deductible is met.

The out-of-pocket maximum is the ceiling. Once your deductible, copays, and coinsurance for covered in-network care add up to that amount in a plan year, the plan pays 100 percent of covered in-network care for the rest of the year. Premiums, out-of-network charges, and anything the plan does not cover do not count toward it.

How they stack up over a year

A simplified example, with made-up round numbers purely to show the sequence: suppose a plan has a $2,000 deductible, 20 percent coinsurance after that, and a $7,000 out-of-pocket maximum. You pay the first $2,000 of covered care yourself. After that you pay 20 cents of every covered dollar while the plan pays 80. If a very expensive year pushes your share to $7,000, everything covered and in network after that point is paid at 100 percent by the plan until the year resets.

Things that quietly change the math

• Family plans often have both individual and family deductibles, and the two interact differently from plan to plan.
• Prescription costs may run through a separate drug deductible.
• Deductibles and maximums reset on the plan year, which is not always January 1 for coverage through work.
• Out-of-network care usually has its own, much higher deductible and maximum, when it is covered at all.

Related: plain-language definitions in the glossary.

Under the Affordable Care Act, most health plans have to cover a specific list of preventive services without charging a copay, coinsurance, or deductible when you use an in-network provider. The list comes from three sources: services rated A or B by the U.S. Preventive Services Task Force, immunizations recommended by the CDC advisory committee, and the preventive guidelines for women, infants, children, and adolescents supported by the Health Resources and Services Administration.

Categories that generally qualify

• Routine immunizations for children and adults, per the recommended schedules.
• Blood pressure, cholesterol, and diabetes screening for the ages and risk groups the recommendations name.
• Cancer screenings such as colorectal, breast, and cervical cancer screening at the recommended ages and intervals.
• Screening and counseling for depression, alcohol use, tobacco use, and obesity.
• Well-woman visits, contraception, prenatal care, and breastfeeding support and supplies.
• Well-child visits and developmental screening from birth through adolescence.

Four details that surprise people

• It applies in network. The same screening from an out-of-network provider can be billed to you normally.
• Screening and diagnosis are billed differently. If a screening turns up something and the visit becomes diagnostic, or a polyp is removed during a screening colonoscopy, some cost sharing can apply.
• Recommendations are specific about age, sex, and risk. A test ordered outside those parameters may be covered as ordinary care instead.
• Not every product follows these rules. Grandfathered plans, short-term plans, and health care sharing arrangements are not required to cover preventive care this way.

Related: preventive services for women.

Call 911 or go to the nearest emergency room for anything that could be life threatening. Chest pain or pressure, sudden weakness or numbness on one side, trouble speaking or a drooping face, serious trouble breathing, heavy bleeding that will not stop, a head injury with confusion or loss of consciousness, a seizure, severe burns, or thoughts of harming yourself all belong in that category. Emergency care is covered by ACA-compliant plans without requiring prior authorization, and federal rules judge an emergency by the symptoms a reasonable person would consider serious, not by the diagnosis you end up with.

Urgent care fits the middle

Urgent care handles problems that need attention today but are not emergencies: sprains and simple fractures, cuts that need stitches, fevers, ear infections, sore throats, urinary tract infections, rashes, mild asthma flares. It generally costs far less than an emergency room visit for the same complaint and usually involves a shorter wait, since emergency departments treat the sickest patients first.

Virtual visits handle a narrow but common set

A video or phone visit works well for medication questions, rashes, pink eye, cold and flu symptoms, follow-ups, and many mental health appointments. It cannot examine an injury, perform a test, or take an image, so anything that needs hands or equipment will be referred onward.

Two things worth doing before you need them

• Find the in-network urgent care nearest your home and your work now, and save the addresses. Searching while you are hurt is a bad time to compare networks.
• Know whether your plan includes a virtual care benefit and how to start a visit, since the process differs by plan.

Related: protections against surprise bills from emergency care.

A network is the set of doctors, hospitals, labs, and pharmacies that agreed to contracted rates with the plan. In network you pay the contracted rate and your cost sharing counts toward your deductible and maximum. Out of network you may pay much more, or everything, depending on the plan.

• HMO: care runs through a primary care doctor, referrals are usually required for specialists, and out-of-network care is generally not covered except in an emergency.
• PPO: no referral needed, and out-of-network care is covered at a lower level, so the premium is usually higher.
• EPO: no referral needed, but coverage stops at the network edge outside of emergencies.
• POS: a hybrid, typically requiring a referral while still paying something toward out-of-network care.

Prior authorization

Some services, such as imaging, planned surgery, durable medical equipment, and certain drugs, require the plan to approve them in advance. Your provider usually submits the request, but the consequence lands on you if it is skipped, so it is worth asking directly whether an authorization is on file before the appointment.

Check three things before every appointment

• That the specific provider, and the facility they practice at, are both in network for your plan this year.
• Whether a referral is required and whether it is already on file.
• Whether the service needs prior authorization, and who is responsible for requesting it.

Related: look up a doctor or find care near you.

A formulary is the list of drugs a plan covers, sorted into tiers. Lower tiers hold generics and cost the least, middle tiers hold preferred brand-name drugs, and the highest tiers hold non-preferred brands and specialty medications. Two plans can cover the same drug at very different tiers, which is why the drug list matters as much as the premium when you are comparing.

Rules that can apply to a specific drug

• Prior authorization: the plan must approve the prescription before it will pay.
• Step therapy: you try a lower-cost drug first, and the plan covers the other one if that does not work.
• Quantity limits: a cap on how much is covered in a given period.

Ways to lower what you pay

• Ask your prescriber whether a generic or a lower-tier therapeutic alternative would work for you.
• Use a pharmacy in the plan network, and check whether it has preferred pharmacies with lower cost sharing.
• For maintenance drugs, ask about a 90-day supply or mail order, which often costs less per month.
• If a drug you need is not covered, you can request a formulary exception, and you have the right to appeal a denial.

Formularies change from year to year. Re-check your medications during every open enrollment, even if you are staying on the same plan.

Related: pharmacy and drug coverage or look up a drug.