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Know the difference: PPO and EPO plans

Blue shield offers Preferred Provider Organization (PPO) plans as well as Exclusive Provider Organization (EPO) plans. Where you live determines which kind of plan you are eligible for.

PPO plans

Our PPO plans provide access to our Exclusive PPO Network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in this network without a referral. You even have the option to receive care from non-participating providers, if you’re willing to pay more out of pocket.

Blue Shield PPO plans are available in the following counties:

Contra Costa El Dorado Fresno Imperial
Inyo Kern Kings Los Angeles
Madera Mariposa Merced Mono
Orange County Placer Riverside Sacramento
San Bernardino San Diego San Francisco San Joaquin
San Luis Obispo San Mateo Santa Barbara Santa Clara
Stanislaus Tulare Ventura Yolo

EPO plans

An EPO plan provides access to our Exclusive network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in our Exclusive EPO network without a referral. However, there is no coverage for services received from non-participating providers, except emergency care services. Members who receive non-emergency care from non-participating providers are responsible for all billed charges.

Blue Shield EPO plans are available in the following counties:

Alameda* Amador* Butte* Calaveras*
Colusa* Del Norte* Glenn* Humboldt*
Lake* Lassen* Marin* Mendocino*
Modoc* Napa Nevada* Plumas*
San Benito* Santa Cruz* Shasta* Sierra*
Siskiyou* Solano* Sonoma* Tehama*
Trinity* Tuolumne*

Know the language: Helpful definitions for common terms

With all the talk about “deductibles” and “copayments,” health care can sound like a foreign language. Here’s a helpful “translation” of important words to help you better understand how health plans work.

Brand drug – A drug produced and sold under the original manufacturer’s brand name. Many brand drugs are included in the Blue Shield Drug Formulary.

Coinsurance – A percentage of the cost for covered services that a member pays under the health plan.

Copayment (or copay) – A fixed dollar amount that a member pays for covered services under the health plan.

Covered services – The medical services and supplies that are covered by the member’s health plan.

Deductible – The amount that a member pays for most covered services before the health plan pays for covered services.

Evidence of Coverage - The contract that defines the terms of health plan coverage.

Formulary – A preferred list of drugs which may include generic and brand-name drugs. In certain plans, members pay less for formulary than non-formulary drugs.

Non-participating provider – A physician, hospital, or other licensed healthcare provider that is not contracted with Blue Shield to provide services to members in a Blue Shield of California or Blue Shield of California Life & Health Insurance Company PPO plan (also called a non-network provider).

Out-of-pocket maximum – The dollar limit on the amount a member has to pay for specified covered services in a calendar year.
For additional definitions, or for the contractual definitions of terms, ask for a copy of the Evidence of Coverage or Policy.

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