Preferred Provider Organizations (PPOs)

What's a PPO?

A PPO is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPOs have networks of doctors, other health care providers, and hospitals.

  • You pay less if you go to providers and facilities that are belong to the plan's network .
  • You can generally go to out‑of‑network providers for covered services, but you’ll usually pay more.

Questions you may have about PPOs:

Do these plans charge a monthly
Yes. These plans usually charge a premium, in addition to the monthly  Part B (Medical Insurance)  premium. 
Do these plans offer Medicare drug coverage (Part D)

Usually. Prescription drugs are covered in most PPO Plans. Check with the plan you’re interested in.

PPOs & drug coverage

If you want prescription drug coverage, you have to join a PPO that offers it.  If you join a PPO that doesn’t offer drug coverage, you can’t join a separate Medicare drug plan.

Can I use any doctor or hospital that accepts Medicare for covered services?

Yes. You can also use out-of-network providers for covered services, if they’re participating in Medicare or accept assignment , but you'll usually pay more.

Before you get services from an out-of-network provider, contact your PPO Plan to ensure the services are medically necessary and covered by your plan. You’re always covered for emergency and urgent care.

Do I need to choose a
primary care doctor ?
Do I have to get a referral to see a specialist?No.
What else do I need to know?
  • Because certain providers are "preferred," you can save money by using a PPO.
  • Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.
  • If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.