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Medicare Advantage PPO Plans

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What is a Medicare Advantage PPO plan?

A Medicare Advantage PPO plan*, or a Preferred Provider Organization plan, is available through a private insurance company contracted with Medicare to provide and coordinate benefits for beneficiaries. Each PPO plan has its own network of doctors and hospitals. Individuals enrolled in a Medicare Advantage PPO plan are allowed to use out-of-network providers for Medicare covered services, but usually for a higher cost.

Covered benefits under a Medicare Advantage PPO plan

Medicare Advantage Preferred Provider Organization (PPO) plan
Are prescription drugs covered? In most cases, yes, but contact the plan to be sure. If you want prescription drug coverage, you must enroll into a Medicare Advantage PPO plan that offers prescription drug coverage.
Do I need to choose a primary care doctor? No.
Do I have to get a referral to see a specialist? Not in most cases, but you may want to check with your plan to be certain.


Medicare Advantage PPO plan costs

If you enroll into a Medicare Advantage PPO Plan, costs associated with the plan include:

  • The Medicare Part B premium. You’ll pay the standard premium of $134 in 2017 if any of the following situations applies: You enrolled in Part B for the first time in 2017; you get billed directly for your Part B premiums; you aren’t currently getting Social Security or Railroad Retirement benefits; and/or you have both Medicare and Medicaid, and Medicaid pays for your premiums. You may also pay a higher monthly premium if your adjusted modified gross income from your tax return two years ago is above a certain amount, or if you owe a late-enrollment penalty for Part B. However, if you enrolled in Part B before 2017 and receive Social Security benefits, your premium might be lower ($109 per month on average).
  • The monthly plan premium, if any, required by your Medicare Advantage plan. Some Medicare Advantage plans have a $0 premium; however, please note that even if your Medicare Advantage plan doesn’t have a premium, you must continue to pay your Medicare Part B premium.
  • Deductibles, coinsurance, or copayments associated with the selected Medicare Advantage PPO plan.

*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.

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