Preferred Provider Organization

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. A PPO may be a good choice for you because:

  • You don’t need a PCP to coordinate your care.
  • You don’t need a referral to see a specialist.
  • You can get care from in-network or out-of-network providers.
  • Higher costs for out-of-network solutions.
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Pros and Cons of Preferred Provider Organizations (PPOs)

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 can also use out‑of‑network providers for covered services, usually for a higher cost, if the provider agrees to treat you. You’re always covered for emergency and urgent care.

Your PPO network may include care and services from certain:
  • Doctors
  • Hospitals
  • Clinics
  • Pharmacies
  • Labs/Imaging Centers
  • Medical Equipment Vendors

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).