Licensed Insurance Agents: 888-323-1149 TTY: 711
Mon - Fri, 8am - 8pm ET

Medicare Advantage PPO Plans

October 6, 2016

What is a PPO Plan?

The acronym “PPO” means “Preferred Provider Organization.” A Medicare Advantage Preferred Provider Organization* is a type of Medicare Advantage plan that is offered to beneficiaries through a private insurance company. These managed care plans typically require plan members to obtain health care services through one or more of its participating doctors, hospitals, and health care facilities. Members generally pay less if they receive in-network health-care services. Services rendered by out-of-network doctors and facilities may not be covered or may be paid at a lower level than would be the case for an in-network provider.

Do PPO plans cover prescription drugs?

Like other types of Medicare Advantage plans, PPO plans may offer the option to receive prescription drug coverage in addition to regular plan coverage. These plans are known as Medicare Advantage Prescription Drug plans (MAPD). Plans differ, so you may want to ask if your plan offers this benefit. If you would like to enroll in a Medicare Advantage Prescription Drug PPO plan that includes prescription drug coverage, you might want to make sure the plan you’re considering covers your prescriptions. Please note that each Medicare plan that includes prescription drug coverage has its own formulary, or list of covered medications – so you’ll probably want to make sure your prescriptions are listed in the plan’s formulary. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

What are PPO doctor requirements?

Generally, Medicare beneficiaries enrolled in Medicare Advantage PPO plans can receive their health care from any doctor or health care provider who accepts Medicare assignment. These plans have network doctors and providers, but plan members are still given the flexibility to choose out-of-network doctors. Be aware that out-of-network care will generally cost more for the beneficiary as the PPO plan will cover less of the expenses. Some Medicare Advantage plans require beneficiaries to choose a primary care doctor to coordinate their health care, but PPO plans do not have this requirement. Additionally, referrals from a primary care doctor are not required for a beneficiary to see a specialist. Like with other aspects of care under a PPO plan, using an in-network plan specialist will usually cost less than using an out-of-network specialist.

What do Medicare Advantage PPO plans cost?

Medicare Advantage PPO plans may require payment of a yearly deductible before beginning to pay for some or all of a beneficiary’s medical bills. After the deductible is paid, beneficiaries normally pay a percentage of their bills, or a co-insurance amount, and the plan pays the rest. You may be responsible for a monthly premium as well, in additional to your Medicare Part B premium. Even if a service was performed out-of-network, the plan might share in the costs, but in some situations you might have to pay the entire amount (for example, if the doctor delivering the service didn’t accept Medicare assignment). A PPO plan usually has a maximum allowable amount for services, which is the most it will pay for a certain service. This amount is similar for services performed in the plan’s network or outside of the plan’s network.

Is a PPO plan right for you?

Only you can decide if any health plan is right for you. A Medicare Advantage PPO plan might work for you if:

  • Your favorite doctor is already a part of the PPO network
  • You want some freedom to direct your own health care but don’t mind working within a list ofpreferred providers
  • You do not want to choose a primary care doctor


*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.