| |
Preferred Provider Organization (PPO) Plan |
Health Maintenance Organization (HMO) Plan |
Private Fee-for-Service Plan (PFFS) |
| Are prescription drugs covered? |
In most cases. If you want prescription drug coverage, you must get it from the plan. The cost for coverage will be included in the premium. |
In most cases. If you want prescription drug coverage, you must get it from the plan. The cost for coverage will be included in the premium. |
Sometimes. If your plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan (Part D) in your area. |
| Do I need to choose a Primary Care Doctor? |
No |
Yes. In most cases, you must see a Primary Care Doctor to get a Referral before you see any other health care provider. |
No |
| Can I get my health care from any doctor or hospital? |
Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost. |
No. You generally must get your care and services from doctors or hospitals in the plan's network (except emergency or urgent care). If the plan has a Point-of-Service (POS) option, you can go out-of-network, but you will pay more than for services in-network. |
In most cases. You can go to any Medicare-approved doctor or hospital that accepts the plan's payment terms for covered services. |
| Do I have to see a primary care doctor to get a referral to see a specialist? |
No |
In most cases. Women don't need a referral for a yearly screening mammogram or an in-network pap test and pelvic exam (at least every other year). |
No |
| What else do I need to know about this type of plan? |
• Contact the plan before you get a service to find out if the service is covered and how much it costs. Follow the plan's rules when needed.
• Regional PPOs (which serve an entire state or multi-state area) limit your out-of-pocket costs but may have a higher yearly Deductible and/or premium than other PPOs
• Extra benefits are often offered for an extra premium. |
• If your doctor leaves, your plan will notify you. You can choose another plan doctor.
• If you get health care outside the plan's network, you may have to pay the full cost of the services yourself.
• Follow the plan's rules, like getting prior authorization when needed.
• Extra benefits are often offered for an extra premium. |
PFFS plans are different from the Original Medicare Plan. PFFS plans are offered by private companies. The private company, rather than Medicare, decides how much it will pay and what you pay for the services you get. Extra benefits are often offered for an extra premium. |
