Medicare Advantage PPO plans offer flexibility to see in-network providers for lower copays (no PCP or referrals needed) or out-of-network doctors at higher costs. They include Part D drug coverage, extra benefits like dental/vision, and a 2025 annual out-of-pocket maximum of up to $9,200.
Medicare Advantage PPO (Preferred Provider Organization) plans combine Original Medicare coverage with added benefits and often lower costs. They provide flexibility while protecting against high expenses.
Lower Copays for In-Network Care
You typically pay lower copays when using in-network providers. Most PPO plans do not require a primary care physician (PCP) or referrals to see specialists, giving you more choice in your healthcare.
Annual Out-of-Pocket Maximum (MOOP)
All Medicare Advantage PPO plans have a yearly limit on your out-of-pocket costs for covered services. In 2025, the maximum MOOP is
$9,200
for in-network services (some plans set lower limits). Once you reach this cap, you pay nothing for Medicare Part A and Part B services for the rest of the year. Many plans also apply the MOOP to additional benefits, such as dental or vision. Plans often have separate in-network and combined in/out-of-network limits.
Out-of-Network Flexibility
You can see any Medicare-accepting provider outside the network, though you’ll pay higher copays or coinsurance.
Additional Benefits
Most PPO plans include Medicare Part D prescription drug coverage, plus extras like dental, vision, hearing aids, gym memberships, and over-the-counter allowances.
Lower premiums than Medigap supplements (many plans have a $0 premium beyond Part B).
Prescription drugs are covered through the plan (no separate Part D needed).
Annual changes to premiums, networks, copays, and formularies are effective January 1—review during the Annual Enrollment Period (October 15–December 7).
Subject to plan rules and annual updates.
Monthly Premium
— Varies by plan; many are $0 (in addition to your Part B premium, $185 in 2025).
Part B Premium
— You must continue paying this (standard is $185/month in 2025; higher for high-income individuals).
Copays & Deductibles
— In-network costs are lower; out-of-network is higher and may include upfront deductibles.
PPO
: Lower premiums but with copays per service and network restrictions for the best costs. Ideal if you’re healthy and want extras.
Medigap
: Higher premiums but minimal or no out-of-pocket costs for covered services. Better for frequent medical needs.
Our licensed North Carolina Medicare agents at Health Plans of NC provide independent, personalized guidance. We’ll compare local PPO plans, review costs, networks, and benefits, and help you find the best fit for your health and budget. Contact us today or compare plans online!