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Blue Access for Producers
 

Blue Choice PPOSM


Our PPO managed health care plans provide for the payment of benefits at a higher level of coverage when the member utilizes our network of preferred providers. These network providers, including physicians, specialty care providers, hospitals, and other health care facilities and practitioners, have contracted with BCBSTX to provide health care services at negotiated rates.

If the member elects to receive care from network providers:

  • They will receive the higher level of benefits (In-Network Benefits)
  • They are not required to file claim forms — Network providers bill BCBSTX for services provided
  • They are not balance billed — Network providers will not bill for costs that are in excess of the BCBSTX allowable amount for covered services.
  • Network providers are responsible for any necessary preauthorization

If the member elects to receive care from providers outside of the network, they may choose:

ParPlan Providers
Providers participating in a direct-payment arrangement with BCBSTX

Out-of-Network Providers
Non-contracting providers

If the member elects to receive care from a ParPlan Provider, benefits for covered services are available at the lower level of benefits (Out-of-Network); however…

If the member elects to receive care from a non-contracting provider, benefits for covered services are available at the lower level of benefits (Out-of-Network); and…
  • ParPlan Providers will file the member's claim forms
  • Members will be required to file their own claim forms
  • ParPlan Providers will not bill the member for costs exceeding the BCBSTX allowable amount for covered services
  • Members will be responsible for amounts in excess of the BCBSTX allowable amount for non-contracting providers — which may be considerable
  • ParPlan Providers will preauthorize necessary services
  • Members must preauthorize necessary services

The PPO plan is available to clients through the Blue Choice Network, one of the largest networks in Texas. Blue Choice provides:

  • Access to the national BlueCard® network when members are outside of Texas
  • Over 600 participating hospitals and facilities in Texas
  • More than 800,000 doctors and 6,000 hospitals contracting with Blue Cross and Blue Shield plans nationwide

For health care services required outside of Texas, members have access to the BlueCard national network of providers.

BCBSTX offers a variety of PPO plans with varying deductible, coinsurance and copayment amount options. All plans include an outpatient prescription drug benefit with either a three-tier or four-tier pharmacy copay design.

The three-tier pharmacy copay plan design includes three tiers of medications that are comprised of:

  • Generic Drugs
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name Drugs

The four-tier pharmacy copay plan design includes four tiers of medications that are comprised of:

  • Generic
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name / Preferred Specialty
  • Non-preferred Specialty Drugs

Prescription drugs are available through retail pharmacies throughout Texas and mail order pharmacy services.

For more detailed information on available benefit designs, a description of the services and supplies that are covered, a listing of those services and supplies that are limited or excluded, terms and general administration or for any questions you may have regarding our products and services, contact us for the phone number of the regional sales office near you.

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