Preferred Provider Organization (PPO)

How 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 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 (for Medicare Part A and Part B items and
services). 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.
  • Check with the plan for more information.