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View or download our convenient new member PPO guide.  

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Your New PPO Plan

Welcome to Blue Shield.

Get started with the basics of your Preferred Provider Organization (PPO) plan

As a PPO plan member, you have a lot of flexibility. The benefits of being a PPO plan member are:

  • You can see any doctor or specialist that you want without a referral. Plus, there are many other ways you can access care.

  • You are not required to see a primary care physician (PCP).

  • You will get the benefit of a discounted rate and pay less out of pocket when you see a doctor in your plan’s network.

  • You have access to our Exclusive PPO Network, which includes more than 46,000 doctors and 350 hospitals across California.

  • You don’t need to visit a PCP first to receive care.

  • You are covered for routine, urgent and emergency care when traveling throughout the country and abroad.

Steps to receiving care

1. Get your ID card

We will send you your ID card in the mail within 10 days after your initial payment has been applied and your enrollment is activated. Your ID card is proof of coverage to use when you go the doctor. It will list the subscriber’s name, member ID, group number and plan type, and can be used by family members covered under your plan. See an example of a PPO plan ID card:
A49608_SubscriberIDCard
Make sure to keep your card handy, so your information is easily accessible when you visit a doctor, hospital or specialist. If you signed up for your plan through Covered California and paid your premium but have not received your ID card within 10 business days, call (855) 836-9705. If you signed up directly through Blue Shield, call (888) 256-3650.

2. Create your online account

You will be able to register for an account as early as 30 days before your plan's effective date. For example, if your plan begins January 1, you can register starting December 1. Once you receive your ID card, use your member ID number to register for a blueshieldca.com account. Then log in, and you will see your personalized account, where you can manage your health coverage all in one place.

  • View or print your ID card

  • Find a provider in your plan's network with our Find a Doctor tool

  • View your billing, claims, benefits, deductibles and copayments, updated daily

  • Chat with a nurse for health advice with NurseHelp 24/7SM

  • Use the Treatment Cost Estimator tool to review out-of-pocket expenses and savings

  • View or change your PCP

  • Get smart tips to control your healthcare costs and many other helpful resources

3. Find a doctor

Our Find a Doctor tool lets you search for doctors, specialists and hospitals online. Simply log in to find information about the doctors and hospitals that are in your plan's network.* A PPO plan does not require you to choose doctors who belong to a medical group. We are contracted with individual physicians as well as multi-specialty medical groups so you can get many of your healthcare needs in a single location. Make sure to choose a doctor who is in your plan’s network to save on costs for covered services. For more details, see your Evidence of Coverage and Health Services Agreement.

* The search results will list providers that are participating in the plan you selected. We make efforts to ensure that our list of providers is current and accurate. However, because providers leave networks from time to time, this list is subject to change and you are encouraged to check with the provider before using their services.

Primary care physicians

We’ve matched you with a primary care physician (PCP) because we believe that the relationship you build with your PCP is important to your overall health and well-being. View your PCP information in your online account at blueshieldca.com and find out more about PCP matching at blueshieldca.com/ppopcp.

With a PPO plan:

  • You do not need a referral to see a specialist or any provider.

  • You are not required to see a PCP.

  • You may change your PCP online, up to once per day.

Primary care physicians are usually general practitioners and include:

  • Family or general practice doctors care for people of all ages.

  • Pediatricians care for people under 18.

  • Doctors of internal medicine care for people 18 and older.

We recommend having a PCP for yourself and your dependents. Having a PCP means you have a doctor you can turn to for healthcare advice—whether it’s preventive care, treating common illnesses and injuries, or help determining if you need to see a specialist. Specialists focus on one area of medicine, such as dermatology, oncology or allergies.

4. Visit your doctor

If you need care, choose the type of doctor you need to see (PCP or specialist) and call that doctor’s office to make an appointment. Be sure to choose a doctor in your plan’s network to save on out-of-pocket costs and don’t forget to bring your Blue Shield ID card with you to your visit.

Many preventive care services such as routine physical exams, screenings and vaccinations are covered 100% under your plan when you visit a doctor or your PCP in your plan’s network.

For other services, you will pay a small fee, known as a copayment, to your doctor for each visit. In most cases, the copayment to see a specialist is different from a general office visit with a PCP.

5. Pay for your care

How you pay for care from network providers

You will get the best value when you see a doctor in your network. Your doctor or hospital will bill Blue Shield for most services. We will determine what you can be charged—the allowable amount—based on our negotiated rates for each service.

If you have a deductible, you will be responsible for paying 100% of the negotiated rate for certain services subject to a deductible until you reach the deductible limit. After the deductible limit has been met, we will share most costs for covered services with you. This means you will pay a certain percentage of costs, or coinsurance, for covered services received from Blue Shield providers, and Blue Shield will pay the rest.

There is a limit to how much you have to spend out of your pocket each year before Blue Shield begins paying 100% for most covered medical services. This is called your plan’s out-of-pocket maximum.

Learn more about paying for health care.

To see an example of how your health plan works, click here.

How you pay for care from non-network providers

With a PPO plan, you have the flexibility to receive covered services from providers that are not in your plan’s network, but your costs will be higher because we do not have negotiated rates with those providers. And, in some instances, services provided by a non-network provider are not covered. If a service isn’t covered, you may be responsible for all billed charges.

To get the most value out of your health plan, it’s important to choose doctors in your plan’s network. For more details about covered services, see your Evidence of Coverage and Health Services Agreement.



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