Preferred Provider Organization (PPO)

How Preferred Provider Organization (PPO) Plans Work:

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Can you get your health care from any doctor, other health care provider, or hospital?

In most cases, you can get your health care from any doctor, other health care provider, or hospital in Preferred Provider Organization (PPO)Plans. Each plan gives you the flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.

Are prescription drugs covered?

In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).

Do you need to choose a primary care doctor?

You don’t need to choose a primary care doctor in PPO Plans.

Do you have to get a referral to see a specialist?

In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists. Benefits you are eligible for will depend on your area and plan providers.

What else do you need to know about this type of plan?

• A PPO plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
• PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

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