Medicare PPO
Compare in-network and out-of-network access, costs, and plan terms.
Network savings and outside care
A Medicare PPO has a provider network. You generally pay less with contracted doctors, hospitals and other providers. You can generally seek covered care outside that network, but you usually pay more and must confirm the provider can treat you under the plan. A PPO is not a guarantee that every provider accepting Original Medicare will accept the PPO’s terms.
Official source: Medicare: PPO plans ↗ · Medicare: Provider network fact sheet ↗
Specialists and approvals
Medicare says a PPO generally does not require you to select a primary care physician or obtain a specialist referral. That does not rule out prior authorization for certain treatments or medicines. Before expensive nonemergency out-of-network care, contact the plan to confirm medical necessity, covered-service status and what the member share will be. Keep the plan’s response.
Official source: Medicare: PPO plans ↗
Price both network scenarios
Compare the in-network and out-of-network copays or coinsurance for each likely service and obtain the plan’s annual medical maximum, including any combined limit. Add the standard Part B premium or your higher SSA-determined premium and any PPO premium. Drug costs under a plan with Part D are separate from the covered Part A/B medical maximum.
Official source: Medicare: Medicare Advantage guide ↗ · Medicare: 2026 costs ↗ · Medicare: PPO plans ↗
Drug coverage must be in the PPO
Most PPO plans include Part D, but Medicare says that when an Advantage PPO lacks drug coverage you generally cannot simply add a separate Medicare drug plan. Verify the particular PPO’s drug benefit before enrollment and price your exact prescriptions at participating pharmacies. Confirm tier and utilization rules, not just that the plan says it has drug coverage.
Official source: Medicare: PPO plans ↗ · Medicare: What drug plans cover ↗
Directory and service area
A PPO member must live in the plan’s service area even if the plan permits some covered care outside its network. Provider networks may change during the year. Confirm a named doctor and hospital with both the plan and office, and check the Evidence of Coverage for referrals, prior approval and specific out-of-network payment terms.
Official source: Medicare: Joining a plan ↗ · Medicare: Provider network fact sheet ↗ · Medicare: Evidence of Coverage ↗