How We Compare Health Plans

BenZen Research & Methodology | Version 1.0

BenZen compares health plans with a method, not a ranking.

We publish that method so you can follow it, check our work, or tell us where we’ve gotten something wrong.

Our approach focuses on people managing Type 2 diabetes who purchase health insurance through the ACA Marketplace, and the agents who help them.

We’re trying to answer three practical questions:

What’s the best plan for me or my client?
What should I look for when comparing coverage?
How did BenZen compare these plans, and can I use the same method?

The answer to the first question is simple: it depends on the person.

Two people with the same diagnosis may have very different medications, doctors, financial circumstances, and healthcare needs.

That’s why our method starts with the person, not the plan.

This is a working methodology, not an independently validated plan-ranking system. We’ll refine it as our research develops.

Our five-step comparison method

We work in order. A plan that fails an essential requirement shouldn’t win on price.

Define the profile. Who needs coverage, and what matters to them?
Screen for conflicts. Flag plans that fail a must-have or need more checking.
Compare the money. Premiums, deductibles, cost-sharing, and out-of-pocket exposure.
Inspect diabetes benefits. Look past the headline numbers.
Explain the trade-offs. What’s strong, what’s weak, and what to confirm.

The result is a shortlist, not a winner.

Step 1: Define the profile

Before comparing health plans, start with the person who needs coverage.

Two people managing Type 2 diabetes may have very different healthcare needs, financial circumstances, and priorities. Here’s what we look at:

Location: State, ZIP code, and where coverage is available.
Coverage year: The year the plan’s benefits will apply.
Finances: Household income, eligibility for premium tax credits, and potential cost-sharing reductions (CSR).
Medications: Exact prescriptions and doses, including insulin and GLP-1 medications.
Providers: Primary care physicians, endocrinologists, specialists, and preferred hospitals.
Expected care: Routine appointments, lab work, prescription refills, and diabetes supplies.
Financial preferences: Whether predictable monthly expenses matter more than a lower premium with potentially higher out-of-pocket costs.

Someone taking inexpensive generic medications who visits a doctor twice a year may have different priorities from someone using insulin, a continuous glucose monitor (CGM), and several specialists.

The comparison should reflect those differences—not assume everyone with diabetes needs the same plan.a year has different priorities than someone using insulin, a continuous glucose monitor (CGM), and several specialists. The comparison has to reflect that.

Step 2: Screen for conflicts

Before comparing costs, determine whether each plan can meet the person’s essential healthcare needs.

A low premium doesn’t mean much if the plan excludes an important medication or doesn’t include a doctor the person needs to see.

Here’s what we check:

Prescription coverage: Is each medication on the plan’s formulary, and at what tier?
Coverage restrictions: Does the medication require prior authorization, step therapy, or have quantity limits?
Provider networks: Are the preferred doctors, specialists, and hospitals in the specific plan’s network?
Plan type: Is it an HMO, EPO, or PPO, and what are the referral and out-of-network rules?
Plan availability: Is the plan, including the appropriate benefit version, available to this person?

We distinguish confirmed conflicts from missing information.

If a required medication is confirmed as excluded, that may eliminate a plan from consideration. But if we can’t verify whether an endocrinologist participates in the network, we flag the uncertainty rather than assume the answer.

Plans that meet the essential requirements move to the shortlist. Plans with unresolved questions remain under consideration but must be verified before enrollment.

The goal is to narrow the choices without overlooking a potentially good fit.t.

Step 3: Compare the money

A low premium doesn’t always mean lower healthcare costs. And a high deductible doesn’t necessarily mean you’ll pay more for routine diabetes care.

We look at the full cost structure, including how different benefits work together.

What we compare	Why it matters
Monthly premium after assistance	What you pay each month to maintain coverage, whether or not you use care
Medical deductible	What you may pay before the plan begins sharing costs for certain medical services
Pharmacy deductible	Whether prescriptions have a separate deductible and which medications are subject to it
Primary care and specialist visits	Copays or coinsurance for routine appointments and ongoing diabetes care
Prescription costs	What you pay for generic, preferred-brand, nonpreferred-brand, and specialty medications
Lab tests and diagnostics	Costs associated with A1C testing, blood work, and other monitoring
Benefits before the deductible	Services or medications that may be covered with a copay before the deductible is met
Out-of-pocket maximum	The annual limit on covered, in-network cost-sharing, excluding premiums and certain other expenses

Why the details matter

Consider two hypothetical plans.

One has a $0 medical deductible but a separate deductible for prescriptions. Another has a $3,000 medical deductible but covers certain specialist visits and medications with fixed copays before that deductible is met.

The first plan isn’t automatically less expensive, and the second isn’t automatically worse.

What matters is which expenses apply to which benefits—and how those benefits match the person’s healthcare needs.

We document our assumptions, distinguish missing information from a confirmed $0 benefit, and explain where the available data cannot support a reliable cost estimate.

Our goal isn’t to predict someone’s annual medical bills with false precision. It’s to help them understand the financial trade-offs before choosing coverage.

Step 4: Inspect the diabetes benefits

Not all health plans handle diabetes care the same way. Two plans with similar premiums and deductibles may offer very different coverage for medications, supplies, and routine care.

We look beyond the headline benefits to examine:

Diabetes-specific cost-sharing: Reduced copays, deductible exceptions, or special coinsurance for diabetes care, when documented.
Prescription medications: Coverage for insulin, GLP-1 medications, and other diabetes treatments, including applicable restrictions.
Supplies and devices: Test strips, glucose meters, continuous glucose monitors (CGMs), and related equipment.
Routine diabetes care: Primary care and specialist visits, laboratory testing, and ongoing monitoring.
Diabetes management programs: Education, coaching, monitoring, or other support services offered by the insurer.

We verify these benefits against the applicable plan documents whenever possible.

A carrier advertising a diabetes management program doesn’t necessarily mean every service is included or available to every member.

The standardized diabetes example

One of the tools we use is the Summary of Benefits and Coverage (SBC), a standardized document that helps consumers compare health plans.

It includes a hypothetical coverage example called Managing Joe’s Type 2 Diabetes, which illustrates how a plan applies its benefits to a defined scenario involving routine diabetes care.

Because the example follows a common framework, we can compare the reported results across different plans.

Sometimes those differences are substantial—even when plans have similar deductibles or carry diabetes-specific names.

But the example has important limitations:

It isn’t a personalized estimate of someone’s healthcare expenses.
It doesn’t reflect an individual’s actual medications, doctors, or treatment needs.
Its summarized totals don’t identify exactly which services account for every difference between plans.

We use the example to investigate how plans differ, not to predict what an individual will spend.

It’s one piece of evidence alongside prescription coverage, provider access, premiums, and the rest of the plan’s benefits.

Every plan’s Summary of Benefits and Coverage (SBC) includes a standardized scenario called Managing Joe’s Type 2 Diabetes, priced under that plan’s own terms. Because the scenario is the same for every plan, it’s a fair yardstick for comparing how plans apply their benefits.

It has limits. It isn’t a personal cost estimate. It doesn’t reflect anyone’s actual drugs, doctors, or negotiated prices. And its totals can’t tell us which services drove the differences.

We use it as supporting evidence, never as the sole reason to recommend a plan.

Step 5: Explain the trade-offs

No health plan is the best choice for everyone. The final step is to explain how each shortlisted plan fits the person’s needs—and where it may fall short.

For every plan under consideration, we document:

Why it’s worth considering: The benefits, coverage features, or costs that make it a potential fit.
What you’re trading: A higher premium, narrower provider network, prescription restrictions, or greater exposure to unexpected expenses.
What the evidence supports: Which findings are confirmed, calculated from published information, or still uncertain.
What to verify: Any medications, providers, benefits, or plan details that need confirmation before enrollment.

How we label our findings

Not every piece of insurance data carries the same level of certainty. We use three evidence labels:

Verified: Confirmed against an applicable, current primary source, such as a carrier’s plan document or formulary.
Derived from published data: Calculated or interpreted using identified sources, with assumptions explained.
Requires confirmation: Information that is missing, inconsistent, outdated, or hasn’t been independently verified.

These labels describe the evidence behind a finding—not whether a health plan is good or bad.

What the comparison produces

The result is a shortlist of plans worth considering, accompanied by an explanation of their strengths, limitations, and unanswered questions.

We don’t assign a universal winner or rely on an unexplained suitability score.

A method someone else can follow is more valuable than a score they simply have to trust.

Why the headline deductible isn’t enough

A plan’s deductible doesn’t tell the whole story about what someone managing Type 2 diabetes might pay for care.

Consider three 2026 Georgia Marketplace plans. Each includes the same standardized diabetes coverage example in its Summary of Benefits and Coverage (SBC), yet the reported results differ substantially.

Plan	Medical deductible	Joe’s diabetes example	Reported cost-sharing
CareSource Diabetes Silver	$5,000	$100	$0 deductible + $100 copays
CareSource Core Gold	$1,500	$1,700	$200 deductible + $1,500 copays
Oscar Silver Simple Diabetes	$6,500	$4,400	$4,200 deductible + $200 copays

What stands out?

A higher deductible didn’t necessarily produce a higher cost in the standardized example.

CareSource Diabetes Silver has a $5,000 medical deductible—more than three times the $1,500 deductible of CareSource Core Gold.

Yet the Diabetes Silver plan’s example shows $100 in patient costs, compared with $1,700 for Core Gold.

That’s a $1,600 difference under the standardized scenario.

A diabetes-focused plan name didn’t guarantee a lower result, either.

Oscar Silver Simple Diabetes carries diabetes-specific branding but shows the highest example total of the three plans: $4,400.

What this tells us—and what it doesn’t

These results demonstrate why we examine how benefits work together instead of comparing deductibles, metal levels, or plan names in isolation.

But they don’t establish which plan is best.

The SBC examples don’t account for a person’s actual medications, doctors, income, or expected healthcare use. And the summarized cost-sharing figures don’t identify precisely which individual services caused the differences.

We can document the differences without claiming to know more than the evidence supports.

That’s the purpose of our comparison method: identify meaningful differences, explain their limitations, and help people ask better questions before enrolling.

Source verification: All figures were verified against the carriers’ 2026 Georgia Summaries of Benefits and Coverage, using the Managing Joe’s Type 2 Diabetes example on page 7. The comparison illustrates differences in standardized cost-sharing; it is not a personalized cost estimate or a recommendation.

Sources: CareSource Diabetes Silver SBC · CareSource Core Gold SBC · Oscar Silver Simple Diabetes SBC

Our sources

Health insurance information is spread across government datasets, carrier documents, formularies, and provider directories. These sources don’t always agree.

BenZen brings that information together to make plan comparisons easier to understand and verify.

Where our information comes from

We primarily use:

CMS Marketplace data: Plan availability, premiums, deductibles, cost-sharing, and other reported plan characteristics.
Carrier Summaries of Benefits and Coverage (SBCs): Standardized benefit descriptions and coverage examples.
Detailed plan documents: Evidence of Coverage and other materials that explain benefits, exclusions, and coverage rules.
Prescription drug formularies: Medication coverage, drug tiers, and applicable restrictions.
Provider directories: Participating doctors, specialists, hospitals, and other healthcare providers.
State Marketplace data: Additional plan information published by state-based exchanges.

What happens when sources disagree?

We prioritize the most current, specific, and authoritative source for the question we’re answering.

For example, a carrier’s applicable SBC is generally our primary reference for its standardized diabetes coverage example. A current formulary is more appropriate for checking medication coverage, while the plan’s provider directory helps us investigate network participation.

We don’t assume that one source is best for every question.

When we identify conflicting information, we investigate the discrepancy, document it, and flag anything that remains unresolved.

In our Georgia research, for example, carrier SBC figures differed from an earlier state data file. We used the applicable carrier documents for the standardized examples rather than silently combining inconsistent figures.

Making our comparisons reproducible

Whenever practical, our research identifies:

The coverage year and geographic area examined.
The exact plans and benefit variants compared.
The source documents and dates reviewed.
Any calculations, assumptions, or exclusions.
Missing information and unresolved discrepancies.

We distinguish information reported directly by a source from calculations or interpretations we’ve made ourselves.

Our goal is simple: someone reviewing the same evidence should be able to understand how we reached our conclusions—and challenge them when necessary..

What we don’t do

Our goal is to make health plan comparisons more useful, transparent, and evidence-based—not to create another ranking system. That means we don’t:

Declare a universal “best plan.” The right coverage depends on the person’s medications, providers, financial circumstances, and healthcare needs.
Assign unexplained suitability scores. We show the evidence and trade-offs behind our conclusions.
Treat plan names or metal levels as proof of better coverage. A diabetes-branded plan isn’t automatically better for someone managing diabetes.
Present standardized examples as personal cost estimates. The SBC’s diabetes example is a comparison tool, not a prediction of someone’s medical expenses.
Fill gaps with assumptions. Missing information doesn’t mean a benefit is unavailable, covered, or costs $0.
Treat unverified information as fact. Prescription coverage, provider participation, and other important details require confirmation.

We don’t start by deciding which plan should win. We start by asking what the evidence actually shows.

Limits and what’s next

This methodology is a working framework, not a scientifically validated plan-ranking system.

Our early research has identified meaningful differences in how Marketplace health plans structure diabetes-related benefits and cost-sharing. But our comparisons are exploratory, involve selected plans, and should not be interpreted as representative of every insurer or Marketplace.

There are also practical limitations:

Plan information changes. Premiums, formularies, provider networks, and benefits can vary by coverage year, location, and plan version.
Published data can be incomplete. Government datasets and carrier documents sometimes contain missing or conflicting information.
Individual needs vary. A comparison based on one person’s circumstances may not apply to someone else.
Our method hasn’t been independently validated. We haven’t yet established whether using it improves consumer understanding or plan selection.

How we’ll improve the method

Our ongoing research will examine how diabetes-related benefits differ across Marketplace plans, how those differences affect comparisons, and whether a structured approach can help consumers and insurance professionals make more informed decisions.

As we learn, we’ll refine the methodology, document material changes, and explain the evidence behind them.

If we find an error, we’ll correct it and note what changed.

Our objective isn’t to tell everyone which health plan to choose. It’s to make the information behind that decision easier to understand, compare, and verify.

Methodology version: 1.0
Status: Working framework; independent validation pending
Last reviewed: October 28, 2026

Ted McNeil
Founder & Principal Broker
BenZen Insurance