EPO, PPO How Does It Work?

Both Anthem Blue Cross and Blue Shield of California are offering EPO or PPO plans in select areas of California.  For example, in LA and Orange Counties, Anthem offers EPO only whereas Blue Shield offers PPO only.  

To further complicate the matter, each carrier treats crossover services differently.  As I am getting this question frequently, I want to clarify how this works.

For Anthem Blue Cross members:

If you have a PPO in 2014 and use services from an EPO provider, you pay per the terms of your PPO contract.  

If you have an EPO in 2014 and use services from a PPO provider, you will be treated as "in-network" but will have to pay for benefits at the higher Tier 2 price level (you get the lower Tier 1 price level with EPO Providers).


For Blue Shield members:

If you have a PPO in 2014, all EPO providers are in the PPO network so you can use the EPO providers the same as the PPO Providers.

If you have an EPO, you cannot use any PPO providers at all and if you do they are considered out of network and you have no coverage.  

As you can see there are major differences in how each Blue carrier treats the crossover of plan usage between PPO and EPO.  


Dave
www.davefluker.com