Medicareful

PPO with Prescription Drugs

A Medicare PPO Plan is a Medicare Advantage Plan where a Private Insurance company provides your Medicare Part A and Part B benefits. In a Medicare PPO Plan, you can get Medical Services from any provider who accepts Medicare. The Medicare PPO has a preferred network of providers "in network" where cost sharing is lower. Other providers are "out of network". Cost sharing is generally higher for "out of network" providers. Premiums will vary depending on the plans available in your area. Depending on the plans available in your area, some of the plans may include Dental, Vision, Hearing, Gym Memberships. Additionally, plans include a Maximum out of Pocket which would put a cap on your financial exposure in a calendar year. This option includes a Medicare prescription drug benefit.

Is this option right for me?

If you like having your drug benefits included in with your other medical services (hospital and doctor), this could be a good choice.
If you enjoy value added benefits, like hearing, vision, dental, gym memberships, this could be a good choice.
If you like having care coordination services to assist you with a chronic condition, this could be a good choice.
If you prefer a lower fixed monthly premium with higher cost sharing when you need to access benefits to a higher fixed monthly premium with lower cost sharing, this could be a good choice.
If you value the freedom of being able to choose out of network providers in special circumstances, this could be a good choice.
If you are satisfied with the Provider network for your basic healthcare needs, this could be a good choice.

Advantages

Financial Exposure to Part A and Part B cost sharing can be capped depending on the specifics of the plans in your area.
Premium can be lower than a Medicare Supplement depending on the specifics of the plans in your area.
Freedom to use "out of network" providers at a higher cost share.
Additional Value Added benefits may be available (like Dental, Vision, Hearing and Gym benefits) depending on the specifics of the plans in your area.
Drug benefit is integrated into plan, so you only have one card and one plan.
Limits exposure to cost for Medicare covered Prescription drugs.
Avoids Late Enrollment Penalty (LEP) for Medicare Part D Prescription Drug Benefits.

Disadvantages

Unknown Out of Pocket costs depending on your level of utilization of services in the Medicare PPO plan.
Medicare Advantage plans are not Guaranteed Renewable like Medicare Supplement plans. In addition, the benefits can be changed on a calendar year basis.
Higher cost sharing to use "out of network" providers.
You do not have the ability to select a specific drug plan based on your prescription drug needs. You get the prescription drug benefit which is bundled in the plan.

Costs

Hospital and Medical Insurance Coverage
Premium for the Medicare PPO plan will vary based on the county of your residence and the plan you choose to enroll in. Generally, there is cost sharing for Hospitalization, Doctor Office visits, diagnostic tests, x-ray, therapy, etc. The cost sharing would differ depending on whether you are seeing an "in network" provider or an "out of network" provider. You will need to review the Summary of Benefits for each of the specific plans in your area to determine the exact out of pocket costs. Plans include a Maximum out of Pocket limit which is a calendar year maximum.

Part D — Prescription Drug Coverage
For those not qualifying for "Extra Help" paying for their prescription drug costs, the premium for the prescription drug benefit is included in the overall plan premium.
Deductible	Varies from $0 to $310 (in 2011) based on the plan selected.
Initial Coverage	Varies based on the plan selected. Standard benefit is 25% co-insurance up to $2,840 (in 2011) in total drug cost. Some plans may have co-payments for Generics, Preferred Brands, Non-Preferred Brands and Specialty drugs in lieu of 25% co-insurance.
Coverage Gap or "Doughnut Hole"	Varies based on plan selected. Some plans may cover Generics in the Coverage Gap. Very Few plans cover some Brand name drugs in the coverage gap. Medicare Beneficiaries pays 100% of discounted Prescription Drug costs until "True Out of Pocket Cost" is equal to $4,550 (in 2011).
Catastrophic Coverage	Once the "True Out of Pocket Cost" is reached, Medicare Beneficiary pays the greater of 5% or $2.50 for Generics and $6.30 for Brand Name Prescription drugs (in 2011).

Part D — Prescription Drug Coverage
Those who qualify for "Extra Help" from the Federal government in paying their prescriptions will have lower cost sharing (and possibly lower premium). To see the 2011 guidelines for cost sharing at the various levels of qualification, click here. To find out if you qualify for Extra Help, visit www.socialsecurity.gov, visit your local Social Security Office or contact your local Medicaid office.