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Preferred Provider Organization (PPO) Plans

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

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

In most cases, you can choose any doctor, other health care provider, or hospital to get your health care in PPO plans. PPO plans have network doctors, other health care providers and hospitals. In each plan you have flexibility to choose doctors, specialists, or hospitals that are not in the plans list but it might cost you more.

Are Prescription Drugs covered in PPO Plans?

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).If you join a Medicare Advantage Plan, the type of drug coverage you can get depends on the type of Medicare Advantage Plan you have:Medicare PPO Plans—You may get services from providers outside the plan network, but you pay less when using plan network providers. PPOs usually offer Medicare prescription drug coverage, but they’re not required to offer it. If the PPO doesn’t offer Medicare prescription drug coverage, you’re not permitted to get coverage by joining a separate Medicare Prescription Drug Plan (PDP).

Can you choose a primary care doctor?

In PPO Plans, you don’t typically need to choose a primary care doctor.

Do I need a referral to visit a specialist?

In most cases, you don’t need a referral to visit a specialist. Your costs for covered services might be lower if you use in network specialists than if you use out of network specialists.

Any other valuable information you should know about PPO Plans?

  • A PPO Plan is not the same as Medicare Part A and Part B or a Medicare Supplement Insurance policy.
  • PPO Plans usually offer extra benefits than Medicare Part A and Part B, but you may have to pay extra for these benefits.
Note: “A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.”
In general, Plans should educate their enrollees when seeking services from Out-of-network/Non-contracted providers. All PPO plans must include the following disclaimer on marketing materials:
Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For a decision about whether will cover an out-of-network service, we encourage you or your provider to ask for a pre-service organization determination before you receive the service. Please call customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.