Doctors & Finding Care

To help you better understand doctors and finding care, here are answers to some frequently asked questions. If you don't find the answer you are looking for, contact Member Service at the number on the front of your ID card.

If you are an HMO Blue®, HMO Blue New EnglandSM, Blue Choice®, or Blue Choice New EnglandSM member, you must choose a PCP. Your PCP is your partner in guiding you through the health care system. In addition, your PCP will serve as your health care advisor when you have questions or need treatment, and will make sure you receive the care you need.

By coordinating your care through a PCP, you can develop a relationship with a trusted health care provider who will become familiar with your health care concerns. If you need a specialist, your PCP can refer you to one—and give your specialist background about your condition and any previous treatment you may have had.

While not all of our plans require that you choose a PCP, having one is a great way to make the most of your Blue Cross Blue Shield of Massachusetts coverage.

Choosing your PCP is important, and there are several factors you should consider when making your decision. You might want a PCP with a particular subspecialty, such as gastroenterology or cardiology, or perhaps you want a PCP who is affiliated with a particular hospital. You might be more concerned with your PCP's education, or maybe location or public transportation access matters to you most. Before choosing a PCP, make a list of the things that are most important to you. Then you can find a PCP in one of three ways:

Once you select a PCP, create an account or login to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card.

Yes. All HMO Blue and HMO Blue New England members must get a PCP referral before seeing a specialist. Because your PCP knows your history and health care needs, he or she is best qualified to help you decide whether a specialist is needed. Blue Choice and Blue Choice New England members have the option to self-refer for covered services at a higher out-of-pocket cost.

Always discuss your concerns with your PCP. Your PCP will work with you to explore all the available options and make sure your medical needs are met.

Blue Cross Blue Shield of Massachusetts does not offer incentives to limit your care. That means your PCP concentrates on making sure you receive appropriate care in the right setting.

While your plan covers most types of treatment, there may be some exceptions based on the specifics of your plan. For example, if your plan does not cover prescription drugs, you will be responsible for paying for those your doctor prescribes. Some services and items your doctor recommends may not be covered by your plan, as well. Be sure to read your subscriber certificate carefully to find out what is covered and what may be excluded.

If you have a condition that requires prompt treatment, but can wait for the time it takes to contact your PCP for direction, this is considered urgently needed care. A sprained ankle, earache, and a fever are examples of urgently needed care.

You may need emergency care because of the sudden onset of a condition with acute symptoms, including severe pain, which are severe enough that the lack of prompt medical attention could reasonably be expected by a prudent layperson, who has an average knowledge of health and medicine, to result in placing your health or the health of another (including an unborn child) in serious jeopardy. A suspected heart attack, stroke, poisoning, loss of consciousness, convulsion, and a suicide attempt are examples of medical emergencies. If you need emergency care, go to the nearest medical facility or call 911 (or your local emergency number).

If you think you need to see a specialist, you should discuss it with your PCP. Your PCP will help you determine whether or not a specialist is needed and refer you to one who is best qualified to treat your condition.

Your network includes a comprehensive listing of doctors in a wide variety of specialties. If your doctor believes you need to see a type of specialist not included in the network, he or she may refer you to one outside the network and those services will be covered.

Finding a doctor is easy and can be done in one of three ways:

Once you select a PCP, create an account or log in to MyBlue to designate your PCP, or call Member Service at the number on the front of your ID card.

If you are an HMO Blue member and receive services without choosing a PCP, those services will not be covered. A PCP must be noted for services to be covered and paid. If you are a Blue Choice member, you should have a PCP on our records, even though you may wish to see providers who are not in the network. Please note that Blue Choice members incur higher out-of-pocket expenses when they self-refer.

Yes. Each member of your family should choose a PCP who best suits their needs. Our New England plans include PCPs in all six New England states.

Yes. You may change your PCP at any time and as often as you choose. You do not have to specify a reason. Your change is effective immediately upon notifying us.

If you have an urgent health care need, call your PCP first. Your doctor will either treat you or advise you on what to do. All of our plan providers have 24-hour telephone coverage.

If you or a family member is having a life-threatening emergency, call 911 or your local emergency care service and get help immediately. Contact your PCP as soon as possible after you've been treated.

If you don't have a PCP and are concerned about coverage for your emergency care, just call the Member Service number on the front of your ID card—they're here to help.

If you need urgent or emergency care outside of our service area, go to the nearest health care facility. Call the Member Service number on the front of your ID card during the next business day.

If you need routine care (checkups, vaccinations, etc.) when traveling, check with Member Service before your appointment.

Because we are dealing with personal information, security is our top priority. For your protection, we have assigned all members a unique password. This safeguards your personal information, and gives you the exclusive ability to update it. We use the best web security practices available to ensure that your personal information is updated only by you.

Most young adults transition between the ages of 18 and 21. We can help with that. Check out our Find a Doctor & Estimate Costs tool to search for a new doctor for your child.