What is a PPO
If you like having the flexibility to choose the doctors, hospitals and other health care providers you use to get care, and you can afford to pay more, a PPO may be the right plan for you and your family.
PPO stands for Participating Provider Option. It’s a type of health plan that lets you choose where you go for care, without a referral from a primary care physician or having to only use providers in your plan’s provider network. It typically has higher monthly premiums and out-of-pocket costs like copays, coinsurance and deductibles.
A PPO may be a good choice for you because:
- You don’t need a primary care physician (PCP) to coordinate your care.
- You don’t need a referral to see a specialist.
- You can get care from in-network or out-of-network providers.
A PPO plan has a certain group of health care providers you can use when you need care. This is called your PPO network.
Your PPO network may include care and services from certain:
- Imaging centers
- Medical equipment vendors
You can get care from providers not in your plan’s network, but you will pay more for your out-of-pocket costs.
How do I know if a provider is in my network?
To make sure a provider is in your plan’s network, search your carrier’s provider network online directory. This allows you to see the doctors, hospitals and other providers who accept members in certain health plans. You can usually search by your plan name to see all the providers in your health plan’s network, or you can search for certain providers you want to use, to see which health plans they accept.
Some carriers include a cost estimator to help you find costs for general visits as well as specific procedures, surgeries, diagnostics and imaging, vaccinations/ immunizations and other services.
How to Use Your PPO
- You may need to get pre-authorization (or pre-notification) from your carrier before getting certain tests or services. Your doctor’s office will call the pre-authorization number on the back of your carriers member ID card to confirm. You can also call before you go for care or to confirm your doctor’s office has gotten the needed authorization.
- For non-emergencies. For a common illness or injury, like a cold, flu, minor cut or burn, you have a few options to get care. These are less expensive than going to the emergency room.
- Call the 24/7 Nurse line. The number is on the back of your carriers member ID card.
- Call your doctor. If the office is closed, call the doctor’s after-hours number. They will either fit you into their schedule or refer you to another doctor or clinic. In some cases, they may have you go to the hospital.
- Visit a retail health clinic or urgent care center. Check Provider Finder to make sure the facility is in your plan’s network.
- In an emergency — When your injury or illness is serious or life-threatening, call 911 or go to the nearest emergency room, even when traveling out-of-state or abroad. You won’t have to pay the higher out-of-network deductible and coinsurance if it is an emergency.
- For specialist, behavioral health or hospital care. You do not need a referral to see a specialist or behavioral health care provider. You also don’t need a referral to visit a hospital. You can get care from an in-network or out-of-network provider, but you will likely pay more for non-emergency services if you don’t stay in network. To find in-network providers and hospitals, search the carrier’s online directory for providers.
- Helpful Hint — No matter which plan you have, before you need care, learn how your plan works, what’s covered and where you can go for care. Knowing how your plan works may save you time and money. Learn more about Making Insurance Work For You »