What is PPO coverage?

If you want the flexibility to choose the doctors, hospitals, and other health care providers you use for care, plus the ability to pay more, PPO coverage may be the right coverage for you and your family.

PPO is the acronym for Participating Provider Organization. It is a type of medical coverage that allows you to choose where to go for care, without a referral from a primary care physician (PCP) or having to use only the medical professionals in your insurer’s medical professional network. You typically have higher monthly premiums and out-of-pocket costs (such as copays, coinsurance, and deductibles).

PPO coverage may be a good option for you for these reasons:

  • You do not need a primary care doctor to coordinate your care.
  • You do not need a referral to see a specialist.
  • You can get health care from both in-network and out-of-network providers.

Provider network

A PPO coverage has a specific group of health care providers that you can go to when you need assistance. This is the network for your PPO coverage.

Your PPO coverage network may include health care and services from certain:

  • Doctors
  • Hospitals
  • Clinics
  • Pharmacy
  • Laboratories
  • Diagnostic Imaging Centers
  • Medical equipment providers

You can receive health care from providers that participate in your coverage network, but you will have more out-of-pocket costs.

How do I know if a provider participates in my network?

To make sure a provider is in your health plan’s network, search Provider Finder, our online directory. Provider Finder lets you know which doctors, hospitals, and other providers accept certain health plan members. You can search by your coverage name to see all the providers that participate in your health plan’s network, or by the providers, you want to use to see which health plans they accept.

Provider Finder also includes a cost calculator that helps you estimate costs for general health visits as well as specific procedures, surgeries, diagnostics and imaging, vaccinations/immunizations, and other services.

If you’re a Blue Cross and Blue Shield of Texas (BCBSTX) member, sign up or log in to Blue Access for Members SM, our secure site for members, to perform a personalized search based on your health plan and network.

How to use your PPO

  • You may need prior approval (or preauthorization) from BCBSTX before you get certain tests or services. The doctor’s office will call the number on your BCBSTX membership card to confirm. You can also call before receiving medical care or to confirm that your doctor’s office received the necessary authorization.
  • In cases that are not emergencies. For common illnesses or injuries, like the flu, minor cuts, or burns, you have a few options for getting medical care. These are less expensive than going to the emergency room.
    • Call the 24/7 Nurseline. The number that appears on your BCBSTX ID card.
    • Call your doctor. They will schedule an office visit for you or refer you to another doctor or clinic. If the office is closed, call the doctor’s after-hours number. In some cases, you may be referred to an urgent care center or hospital.
    • Visit a clinic inside a pharmacy or an urgent care center. Check the Provider Finder to make sure the facility is in your coverage network.
  • In an emergency. When you have a serious or life-threatening injury or illness, call 911 or go to the nearest emergency room, even if you’re out of state or abroad. You won’t have to pay the higher out-of-network deductible or coinsurance as long as it’s an emergency.
  • For specialist, mental health, or hospital care. You do not need a referral to see a specialist or mental health professional. You also don’t need a referral to visit a hospital. You can receive care from a network or non-network provider, but you may have to pay more for non-emergency services if you use an out-of-network provider.

 

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