Preferred Provider Organization (PPO)

Total Freedom To Choose Your Provider– In or Out of Network

Choose In-network providers
One of the best ways for members to control costs and get the most from their PPO plan is to choose an in-network, participating provider to treat your medical conditions and provide important preventive care checkups and tests. PPO plans require the member to obtain referrals to see specialist.

Choose out-of-network providers
Members have the choice to see any doctor; however, when they receive care from a doctor or facility that is not in the network, out-of-pocket costs will be higher. Members using out-of-network services must pay the entire cost of any care until they meet an annual deductible. Once the deductible is met, coverage begins and members pay a percentage of the cost (coinsurance) of subsequent care.

Here is a summary of benefits and how a PPO works for In-network care:

Routine Medical Care (such as physical exams, mild fever and pains, chronic pain and, headaches, colds and flu).

  • The Primary Care Physician (PCP) will provide medical advice and/or service for a predefined office visit co-payment.

Specialty Care (such as orthopedic or heart disease)

  • In a PPO the member will seek care from a Specialist without the requirement of a referral from a PCP.
  • All services are subject to a predefined office visit co-payment.

Retail Prescription Drugs

  • Members fill their prescriptions at a participating pharmacy for a predefined co-payment.
  • Members fill their maintenance prescriptions at a participating pharmacy and/or a mail order program for a predefined office visit co-payment.


Hospital Care (such as inpatient care and surgery, or outpatient surgery):

  • or non-emergency care, the PCP and or Specialist will coordinate all hospital care.


Cost Sharing Option (often may refer to services such as inpatient care, outpatient surgery and procedures, radiology and laboratory services):

  • Under this cost-sensitive option, select services are frequently subject to a deductible and coinsurance rather than provided at 100% subject to a co-payment.


Here is how a PPO works for out-of-network care. All services are subject to a deductible and co-insurance as well as usual and customary rates (UCR).