Plans & Coverage

Here you'll find answers to specific questions about services and/or situations covered by your plan. While different plans offer different levels of coverage, the following will provide you with some general guidelines and information on getting answers regarding your plan.

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 are an HMO Blue, HMO Blue New England, Blue Choice, or Blue Choice New England 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.

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:

  • Use our Find a Doctor service and create your own Provider Directory.
  • You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
  • You can also call our Physician Selection Service at 1-800-821-1388 if you'd like help selecting a PCP.

Once you select a PCP, create an account or log in to Member Central 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 EnglandSM 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 EnglandSM members have the option to self-refer for covered services at a higher out-of-pocket cost.

As a general rule, Blue Cross Blue Shield of Massachusetts will not pay for care from a specialist without a referral from your PCP. However, the following are instances when you do not need a referral:

  • Emergency care.
     
  • For HMO Blue and Blue Choice members, covered services from a network obstetrician, gynecologist, or certified nurse midwife, or gynecological services and other women's health services from a network family practitioner.
     
  • A routine eye exam every two years for HMO Blue New England and Blue Choice New England members.
     
  • An annual routine eye exam for HMO Blue and Blue Choice members.
     
  • Blue Choice members have the option to self-refer at a higher level of out-of-pocket costs for any other covered service.

Create an account or log in to Member Central to review your benefits.

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 and Blue Shield 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 upon the specifics of your particular plan. For example, if your plan does not cover prescription drugs you will be responsible to pay for the medications your doctor prescribes. Be sure to read your subscriber certificate carefully to find out what is and is not covered.

Based on the type of plan that a member has and the design of their plan, colonoscopies can process under one of two benefits. The cost of the service could fall under their Surgery as an Outpatient benefit or their Routine Adult Physical benefit. The liability is determined by the procedure(s) performed as well as the outcome or diagnosis determined at the visit.

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.

The 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.

If you are an HMO Blue member you will need a PCP referral for services except for visits to your PCP, covered services from a network obstetrician, gynecologist, certified nurse midwife, gynecological services and other routine women's health services from a network family practitioner, and hearing and vision exams (once yearly for HMO Blue and Blue Choice members, once every 24 months for New England plan members).

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

  • Use our Find a Doctor & Estimate Costs service and create your own Provider Directory.
  • You can obtain a Provider Directory for your plan by calling 1-800-262-BLUE (2583).
  • You can also call our Physician Selection Service at 1-800-821-1388 if you'd like help selecting a PCP.

Once you select a PCP, create an account or log in to Member Central 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.

Your first step is to call Member Service at the number on the front of your ID card. Our representatives are trained to help resolve any problems or concerns you may be having.

Your most recent Explanation of Benefits shows deductible amounts met for the current year. You can also call Member Service at the number on the front of your ID card.

Most of our plans cover routine physical exams and immunizations. Check your benefit literature or call Member Service at the  number on the front of your ID card for information about your specific plan.

If you need emergency medical attention, go to the nearest medical facility or call 911 (or the local emergency number). If your medical need is not an emergency, please call Member Service at the number on the front of your ID card.

Congratulations! You'll be happy to know that maternity benefits are part of nearly every plan we offer. Your subscriber certificate will tell you what services are covered. Some plans also require that you call to notify us of an expected maternity admission in advance, while others do not have this requirement.

New parents sometimes forget to update their Blue Cross Blue Shield of Massachusetts membership records when a baby is born so that claims will be paid according to your plan benefits without delay.

And don't forget, Living Healthy Babies®’ is always available when you need it, providing answers to baby questions from parents and parents-to-be.

Yes. Lab tests, X-rays, and other medical tests are covered when ordered by your physician. Coverage will vary from plan to plan. Check your subscriber certificate for details.

No. Marriage blood tests are not "medically necessary" and are not covered.

Exams required to participate in school, sports, camp, etc., are not covered. However, routine physical exams are, according to an age-based schedule. See your subscriber certificate for details.

For children under age 12, HMO Blue and Blue Choice covers preventive dental care when provided by a Blue Cross Blue Shield of Massachusetts participating dentist. This includes one initial exam per child, followed by one periodic exam every six months, one cleaning every six months, one fluoride treatment every six months and bitewing X-rays every six months. (HMO Blue New England, Blue Choice New England, Blue Care Elect, and our indemnity products do not cover this benefit.)

We also offer separate dental coverage through our Dental Blue® and Dental Blue PPO plans. Create an account or log in to review your dental benefits.

HMO Blue New England and Blue Choice New England include chiropractic coverage as part of their benefit plans. For other products, you must have a "Chiropractic Rider" in order for you to have chiropractic coverage.

As a result of the health care reform law in Massachusetts, changes have been made that affect dependent eligibility.

For more information, visit Health Care Reform.

Our HMO Blue, Blue Choice, and Blue Care Elect PreferredSMplans include coverage for one routine eye exam per calendar year. Our HMO Blue New England and Blue Choice New England plans include coverage for one routine eye exam every 24 months as long as you see a network provider.

In an emergency situation, call 911 (or your local emergency number) or go to the nearest medical facility.

Medical policies are scientific documents that define the technologies, procedures and treatments that are considered investigational, medically necessary, and not medically necessary. Medical policy statements contain conclusions about whether a technology, procedure, treatment, supply, equipment, drug or other service improves health outcomes for the health plan's population and therefore is covered or not covered.

Learn more about medical policies.