Know Your Health Plan (HMO vs PPO)

Health plans like HMOs and PPOs use certain groups of doctors, hospitals and other health care professionals who provide a full range of covered health care services. These are called provider networks. When looking for a provider, it's important to know about your network and the choices you have.

Which Health Plan or Network Do You Have?

Your health plan or network is shown on the front of your Blue Cross and Blue Shield of Texas (BCBSTX) member ID card. If you have questions about which network you have, call the Customer Service number on the back of your card.

Tips for HMO Health Plan Members

  • Always go to your Primary Care Provider (PCP) first. When you apply for health insurance, you will choose or will be assigned a PCP. Your PCP is often a partner in keeping you healthy. A pediatrician can serve as your child’s PCP. An OB/Gyn can serve as a female member’s PCP.
  • Stay in-network. If you visit a doctor or a hospital that is not in your network, you will be responsible for the full cost of your care, in most cases. Use Provider Finder® to find doctors, specialists, hospitals and pharmacies in your network. You can also check if labs or imaging centers are in your network before having tests. Register or log in to Blue Access for MembersSM, our secure member website, for a personalized search experience based on your health plan and network. Also, learn how to avoid surprise medical billing.
  • Get a referral for a specialist. If you need to see a doctor for a specific condition, your PCP will refer you to a specialist. Check Provider Finder to make sure the specialist is in your network. You do not need a referral from your PCP to see your in-network OB/Gyn.
  • Get prior authorization. Certain tests and procedures must be pre-approved before you go as described in your benefit documents. You or your doctor must call the prior authorization (pre-certification) number on the back of your member ID card. Learn more about prior authorization and which services and drugs require this step.
  • Use the ER for emergencies only. If your illness or injury is serious or life-threatening, call 911 or go to the nearest emergency room. You don't have to stay in-network.
  • Know where to go. Before you go for care, make sure you know how your plan works, what’s covered and where to go. It may save you time and money. Learn more about Making Your Insurance Work For You

Tips for PPO Health Plan Members

  • Stay in-network. If you visit a doctor or a hospital that is not in your network, you will be responsible for the full cost of your care, in most cases. Use Provider Finder® to find doctors, specialists, hospitals and pharmacies in your network. You can also check if labs or imaging centers are in your network before having tests. Register or log in to Blue Access for MembersSM, our secure member website, for a personalized search experience based on your health plan and network. Also, learn how to avoid surprise medical billing.
  • Find a doctor. You don't need a referral to see a doctor or other health care professional for a specific health issue, but whoever you choose must be in your plan's network to avoid paying higher out-of-network costs. Check Provider Finder to find an in-network specialist. You'll see some regions in Texas have a low number of doctors or providers offering care - or none at all. Find your region to see how many offer care near you.
  • Get prior authorization. Certain tests and procedures must be pre-approved before you go as described in your benefit documents. You or your doctor must call the prior authorization (pre-certification) number on the back of your member ID card. Learn more about prior authorization and which services and drugs require this step.
  • Use the ER for emergencies only. If your illness or injury is serious, call 911 or go to the nearest emergency room. You don't have to stay in-network.
  • Know where to go. Before you go for care, make sure you know how your plan works, what’s covered and where to go. It may save you time and money. Learn more about Making Your Insurance Work For You