How PPO Plans Work

A Medicare PPO 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 can also use out‑of‑network providers for covered services, usually for a higher cost, if the provider agrees to treat you  and hasn’t opted out of Medicare. You’re always covered for emergency and urgent care.

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 PPO Plans. Each plan gives you 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 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, no. But if you use plan specialists (in-network), your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).

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

  • Because certain providers are “preferred,” you can save money by using them.
  • Benefits very by plan and location. Discuss your options with a licensed Medicare insurance agent.