PPO Plans

For people who want more flexibility and choice from their health care plan, our PPOA type of health plan with a network of providers who are "preferred", that is, a member can visit these preferred in-network physicians and don't need to choose a primary care physician. In some PPOs, members can also visit non-preferred, or out-of-network providers, but may have to pay a higher fee or copayment. plans are a great option. Our PPO plans offer the same reliable coverage you expect from Blue Cross Blue Shield of Massachusetts, but without the need for referralsIf a PCP determines that an individual requires specialized care, the PCP may "refer" that person to an appropriate specialist. A referral is often required by a managed care plan before the plan will cover certain services. and more choice in doctors and hospitalsAn institution whose primary function is to provide diagnostic and therapeutic inpatient services, for a variety of surgical and non-surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care. .

You'll get the best benefits if you choose providers in the nationwide networkA group of health care providers under contract with a managed care company within a specific geographic area. , however you can also choose to see providers outside the network for care.

Our PPO plans differ in cost and benefits, but no matter what plan you choose, it will have these features:

• You are not required to select a primary care provider (PCP)A provider, usually a family or general practitioner, internist, or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals, and other providers as necessary. Under some benefits plans, a referral by the primary care provider is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's providers. .
• You don't need referrals from your PCP to see specialists
• Your care is covered when doctors and hospitals are in your plan network

Generally, our PPO plans cover these types of care:

• Inpatient and outpatient medical care
• Mental health/substance use
• Prescription drugA drug that has been approved by the Federal Food and Drug Administration as dispensable only with a licensed physician's prescription. benefits
• Preventive care with no out-of-pocketCopayments, deductibles, or fees paid members for health services or prescriptions. costs

To get the specifics of your plan, check your subscriber certificate or visit Member Central and click on the Using My Plan tab. Your member ID cardIdentification cards are provided to all participants for proper identification under their group health plan. ID card information helps providers verify patient eligibility for coverage. contains valuable information so it's important for you to know how to read your ID card. Watch our Managed Care video to learn more about your health plan.

Depending on the plan you choose, you may be required to pay the following out-of-pocketCopayments, deductibles, or fees paid members for health services or prescriptions. before your insurance covers at 100 percent:

• DeductibleThe dollar amount that a member must pay for health care services before a health plan will cover eligible services. For example, if a member's deductible is $500, the member will pay that amount, out of pocket, before the health plan will cover any eligible services. —The amount you pay before your insurance begins picking up any of the costs for certain services. Deductibles are typically between $500 and $2,000.
• CopaymentThe amount that a plan member must pay the provider at the time of service. Also called a copay, this amount varies depending on the specifics of a given health plan contract. —The cost you're required to pay for certain services or prescription medications. Your copayments will vary depending on your plan and the type of service or medication you receive. Watch our Copayment video to learn more about copayments.
• Co-insuranceThe portion of eligible expenses that plan members are responsible for paying, most often after the deductible is met. Co-insurance is usually determined as a percentage of the total provider's actual charge, or the allowed amount. —A percentage of the cost a doctor or hospital charges that you're required to pay.

You'll get the best benefits if you choose providers in the nationwide network, however you can also choose to see providers outside the networkA group of health care providers under contract with a managed care company within a specific geographic area. for care.

Note: If you have a plan with Hospital Choice Cost Sharing, you will have different out-of-pocket costs depending on the hospital where you choose to get care.

Compare costs for care, make smart choices
Our Medical Cost Comparison Guide allows members of our PPO plans to compare the approximate costs of medical procedures at health care providers across the country. By providing our members with cost and quality information, they have the data they need to make better informed decisions.

This powerful tool provides cost information on more than 100 procedures, including average and high and low costs for each health care provider, PPO members make more informed decisions.

You can find an in-network health care provider using our Find a Doctor search.

To see the specifics of your benefits, log in to Member Central and click on the Review My Benefits link.

Other Information

Have more questions? You can find definitions of other common medical terms or get answers to FAQs 24/7.

Your member ID card contains valuable information so it's important for you to know how to read your ID card.

Your plan allows you to see doctors from our nationwide network of preferred providers. Unlike HMO plans, you don't need to get referrals for specialist services or choose a PCP. However, it's highly recommended that you choose a PCP in order to better coordinate your care.

Another benefit of choosing a PPO plan is that you are covered for out-of-network care. However, in most cases, you'll pay more for care from providers outside your network than from preferred providers in your network.

Find a Doctor or Hospital in Massachusetts

Find a Doctor PCPs, Specialists, and Physicians of Choice

Find a Hospital/Facility Hospitals, Ambulatory Surgi-Centers, Diagnostic Imaging Centers, etc.

Search for other providers

• Find other types of providers, including specialists, dentists, vision care providers, and others in Massachusetts

• Find doctors, hospitals, or other providers outside Massachusetts

Watch our Primary Care Provider and Making the Most of Your Doctors Appointment videos to learn more about choosing the right doctor and making the most of your medical visits.

Choose In-Network Providers and Reduce Your Costs
When your plan renews on or after January 1, 2012, we will begin paying out-of-network health care providers for your covered services based on a "usual and customary" fee schedule, instead of the health care provider's actual charges.

What this change means for you
You would be responsible for the difference between what your out-of-network health care provider actually charges for care and what is allowed under our usual and customary fee schedule. This would be in addition to any copayments, deductible, and co-insurance that apply to your care. This means you would likely pay more when you get covered care outside your PPO network after your plan renews since out-of-network providers can charge as much as three to five times more than in network providers for the same services.

This could mean a significant increase to your out-of-pocket costs for care you receive from an out-of-network provider.

This change does not apply to emergency medical care. You are always covered at the in-network level in an emergency.

Let's Look at Some Examples
All dollar amounts are not actual charges and are hypothetical and for illustrative purposes only.

1. After the member has met his or her deductible.

What you can do
The easiest way to avoid these additional costs is to find an in-network health care provider within the Blue Cross Blue Shield national PPO network. Since you have a PPO plan, you can see any in-network health care provider across the nation without a referral.

You can find an in-network health care provider using our Find a Doctor search.

Hospital Choice Cost Sharing
If your plan includes Hospital Choice Cost Sharing, what you pay for certain services depends on the hospital where you choose to get care. Our Hospital Choice Cost Sharing page can help you understand the your costs and care options.

Quick Start Guides—An easy to follow introduction to PPO plans.

Deductible Education Sheets—See what medical care is subject to the deductible.

• Preferred Blue PPO Deductible plans
• PPO Saver Deductible plans
• Blue Care Elect Deductible plans

Get the Most Value From Your Plan—This downloadable guide provides six practical steps you can take to begin using your plan more effectively.

Summary of Health Plan Payments—A quick guide to your Statement.