What Is a PPO | Blue Cross and Blue Shield of Texas

If you like the flexibility to choose the doctors, hospitals, and other health care providers you use for care, and can afford to pay more, a ppo may be the right plan for you and your family.

ppo stands for Participating Provider Organization. It is a type of health plan that allows you to choose where to go for care, without a referral from a Primary Care Physician (PCP) or without having to use providers only in your plan’s provider network. typically have higher monthly premiums and out-of-pocket costs like copays, coinsurance, and deductibles.

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a ppo may be a good option for you because:

• You do not need a PCP to coordinate your care.
• You don’t need a referral to see a specialist.
• You can get care from in-network or out-of-network providers.

provider network

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A ppo plan has a certain group of health care providers that you can use when you need care. this is called your ppo network.

Your ppo network may include care and services from certain:

• doctors
• hospitals
• clinics
• pharmacies
• laboratories
• image centers
• medical equipment suppliers

You can get care from providers that aren’t in your plan’s network, but you’ll pay more out-of-pocket.

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

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

The provider finder also includes a cost estimator to help you find the costs of general medical 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, register or log in to blue access formemberssm, our secure member website, for a personalized search based on your health plan and network.

how to use your ppo

• You may be required to obtain prior authorization (or preauthorization) from bcbstx before receiving certain tests or services. Your doctor’s office will call the prior authorization number on your bcbstx member ID card to confirm. You can also call before receiving care or to confirm that your doctor’s office has obtained the necessary authorization.
• for non-emergency situations.For a common illness or injury, like a cold, flu, minor cuts or burns, you have a few options for getting care. these are less expensive than going to the emergency room.
  • call the 24/7 nurse line. the number appears on your bcbstx member ID card.
  • Call your doctor. they will fit you into their schedule 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 asked to go to an urgent care center or hospital.
  • Visit a retail health clinic or urgent care center. check the provider locator to make sure the facility is in your plan’s network.
  • in an emergency. When your injury or illness is serious or life-threatening, call 911 or go to the nearest emergency room, even when traveling out of state or in the Foreign. You won’t have to pay the higher out-of-network deductible and coinsurance if it’s an emergency.
  • for specialty, behavioral health, or hospital care. You do not need a referral to see a specialist or behavioral health provider. You also don’t need a referral to visit a hospital. You can get care from an in-network or out-of-network provider, but you’ll likely pay more for non-emergency services if you don’t stay in network.

  Helpful Tip: No matter what plan you have, before you need care, find out how your plan works, what’s covered, and where you can go for care. Knowing how your plan works can save you time and money. learn more about how to make insurance work for you.

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