Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

March 2018

Correction to HMO Plans – PCP Selection and Referral Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) HMO plans are:

  • Blue Advantage HMOSM
  • Blue Advantage PlusSM
  • Blue EssentialsSM
  • Blue Essentials AccessSM
  • Blue PremierSM
  • Blue Premier AccessSM

Corrections to clarify Blue Advantage Plus HMO and Blue Essentials Access are bolded in the table below.

Blue Essentials Access and Blue Premier Access are considered “open access” HMO plans where no Primary Care Provider (PCP) selection or referrals are required when the member uses participating providers in their network.

For Blue Advantage HMO, Blue Essentials and Blue Premier where referrals are required, it must be initiated by the member's designated PCP and must be made to a participating physician or professional provider in the same provider network.

The table defines when a PCP and referrals to specialists (except OB-GYN) are required and when they are not required. (Note: Members can self-refer to in-network OB/GYNs – no referrals are required.) If an in-network physician, professional provider, ambulatory surgery center, hospital or other facility is not available in the member's applicable provider network, preauthorization is required for services by an out- of-network physician, professional provider, ambulatory surgery center, hospital or other facility, through either iExchange® or by calling the preauthorization number on the back of the member ID card.

Additional services for all HMO plans may require preauthorization. A complete list of services that require preauthorization or a referral for in and out of network benefits is available on the BCBSTX provider website under Clinical Resources/Preauthorization/Notification/Referral Requirements.

HMO Plan Designated PCP Required Referrals Required for In-Network Providers Out-Of-Network Benefits Available with Higher Member Cost Share
Blue Advantage HMO Yes Yes No
Blue Advantage Plus HMO Yes Yes Yes
Blue Essentials Yes Yes No
Blue Essentials Access No No No
Blue Premier Yes Yes No
Blue Premier Access No No No

*Prior to referring a Blue Advantage Plus member to an out-of-network provider for non-emergency services, please refer to Section D Referral Notification Program, of the Blue Essentials, Blue Advantage HMO and Blue Premier provider manual for more detail including when to utilize the Out-of-Network Enrollee Notification forms for Regulated Business and Non-Regulated Business.

Sample HMO ID cards and other benefit plan ID cards are available on the BCBSTX provider website.


  • The Blue Essentials, Blue Advantage HMO and Blue Premier physician, professional provider, facility or ancillary providers are required to admit a patient to a participating facility, except in emergencies.
  • Blue Advantage Plus is a benefit plan that allows members to use out-of-network providers. However, members must understand the financial impact of receiving services from an out-of-network physician, professional provider, ambulatory surgery center, hospital or other facility.