Participating Provider Option (PPO)
The Blue Cross and Blue Shield of Illinois (BCBSIL) Participating Provider Option (PPO) plan offers a variety of benefits, including medical coverage, emergency care, vision services and more. Read on to learn more about this flexible plan.
The PPO plan gives you freedom of choice, flexibility and a broad range of benefit options. With the PPO product:
- There is no need to select a primary care physician; you can choose a doctor whenever you need care.
- You do not need a referral to see a specialist or to get another opinion about a medical condition.
- The choice of doctors and hospitals is always yours.
PPO Advantages
With the PPO plan, you have access to a large network of contracting doctors and hospitals in the national BlueCard® network.
- The BlueCard network includes more than half a million contracting doctors and specialists—over 34,000 in Illinois alone.
- The network also includes more than 5,000 contracting hospitals across the country.
With the PPO plan, benefits may include coverage for:
- Doctor office visits
- Inpatient hospital services
- Outpatient hospital services
- Maternity care
- Hospital emergency medical and accident treatment
- Breast and cervical cancer screenings
- Muscle manipulation services
- Physical, speech and occupational therapies
- Infertility treatment
- Mental health and substance abuse treatment
- Reconstructive surgery following a mastectomy
Preventive Care
Coverage may also include preventive care benefits for well-child and adult care, including:
- Physical exams
- Diagnostic tests
- Immunizations
Group plan coverage may vary.
Use Network Doctors and Hospitals for Greater Benefits
Benefits are paid at the highest level when you receive care from network PPO doctors and hospitals. When you receive care from network PPO doctors and hospitals:
- There are no claim forms to complete.
- There are no up-front payments for medical services (except for copayments) and charges for non-covered services.
- There’s no balance billing—network doctors and hospitals accept Blue Cross and Blue Shield of Illinois’ negotiated rates.
You always have the option to receive care outside the network, but your benefits will be paid at a lower level.
The PPO plan provides emergency care coverage for members, even when traveling out-of-state or abroad.
- In an emergency, members can seek care from an emergency room or other similar facility.
- Call 911 or other community emergency resources to obtain assistance in life-threatening situations.
- Emergency room care at any hospital is covered (subject to plan deductible and coinsurance/copayments).
- Some group plans require that the member, a family member or a friend contact the Medical Services Advisory (MSA) upon hospital admittance.
Whether you’re traveling across the country or around the world, you can take your Blue Cross and Blue Shield of Illinois PPO health care benefits with you.
National Coverage
The PPO plan includes nationwide access to contracting doctors and hospitals in PPO networks linked through the BlueCard® PPO program when you or your covered dependents live, work or travel anywhere in the United States.
Members who use a BlueCard® PPO network doctor or hospital receive the highest level of benefits.
International Coverage
When you travel outside the United States and need urgent or immediate care, you are covered. Blue Cross and Blue Shield of Illinois contracts with doctors and hospitals in more than 200 countries, but you may receive care anywhere you choose.
- When receiving care at BlueCard Worldwide® contracting hospitals you will not have to pay up-front for inpatient care
- You are responsible for the out-of-pocket expenses (deductible, copayment, etc.)
- You also have coverage at non-BlueCard Worldwide hospitals, but you may have to pay the doctor or hospital up-front for care.
Federal and State of Illinois laws require group health plans and insurers to provide coverage for reconstructive surgery following a mastectomy. These laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for:
- Reconstruction of the breast on which the mastectomy has been performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
- Prostheses and treatment for physical complications for all stages of mastectomy, including lymphedemas.
Blue Cross and Blue Shield of Illinois (BCBSIL) plans traditionally offered this coverage before it was required. We continue to provide this coverage if the procedures are provided by a licensed physician according to each plan’s provisions. Coverage may also include benefits for annual mammograms.
If you have prescription drug coverage through Blue Cross and Blue Shield of Illinois:
- Your coverage may be based on either the standard formulary
or the generics plus formulary - Your benefit plan includes a mail service program that offers you the convenience of having covered maintenance medications delivered directly to you.
- Your plan also includes a specialty pharmacy program, through which members using covered self-injectable medications can have them delivered directly to them or their doctor, as well as receive services that may help them in managing their therapy.
View the Specialty Pharmacy Program Drug List which includes a reminder about coverage for self-administered specialty medications. - Helpful information is provided to assist you in understanding your prescription drug coverage and options, including convenient services and any limitations.
- A variety of online tools are available that can help you learn more about prescription drugs and manage your pharmacy benefits. Just log in to Blue Access for MembersSM and visit your Rx Drugs page.
