Does Blue Shield of California Cover Out-of-State Care?

Blue Shield of California does cover out-of-state care, but how much and what kind depends almost entirely on the plan you carry. Members with an employer-sponsored PPO, POS, or Active Choice plan can use covered benefits at participating providers in all 50 states through the BlueCard program. HMO members and people who bought an individual or family PPO (including through Covered California) are generally limited to emergency and urgent care when they leave the state.¹²

What Your Plan Type Covers Outside California

Blue Shield sorts its plans into distinct categories for out-of-state purposes, and members are sometimes surprised by where their plan lands.

Employer-sponsored PPO, POS, and Active Choice plans. These plans give you the widest access. Through BlueCard, you can use covered medical benefits at participating providers in all 50 states and in more than 200 countries. About 85 percent of U.S. providers participate in BlueCard. Dental, vision, and prescription drugs are not part of the BlueCard medical network, but most other covered services are.¹

HMO plans. Coverage outside the HMO service area is limited to emergency care, urgent care, and authorized follow-up. Non-emergency, non-urgent services are not covered unless your medical group or Blue Shield HMO has referred and authorized them ahead of time.³

Individual and Family PPO plans, including plans bought through Covered California. These are PPO plans in name, but for out-of-state purposes they behave like HMOs. Coverage is limited to emergency and urgent care when you’re outside California.²

EPO plans. EPO members can generally access out-of-state care through BlueCard, and services that have been prior-authorized by the claims administrator may also be covered. Some EPO products have limited out-of-area benefits, so check the back of your ID card or your Evidence of Coverage.⁴⁵

Trio HMO. This narrow-network product covers urgent and emergency care while you travel, through BlueCard and Blue Shield Global Core, in line with other HMO plans.⁶

The line between an employer PPO and an individual PPO is the one to watch. A Blue Shield PPO purchased through Covered California does not carry the same nationwide access as a Blue Shield PPO issued through an employer.

How BlueCard Works at the Provider’s Office

BlueCard connects independent Blue Cross and Blue Shield plans across the country through a single electronic claims system. When you see a BlueCard-participating provider in another state, the provider files the claim with the local Blue plan, which sends it back to Blue Shield of California for processing under your benefits.⁷

At the office, show your Blue Shield ID card. The three-character prefix on the card tells the provider which home plan holds your contract. You may be asked for your copay or deductible amount at the visit; otherwise the claim is paid to the provider and you don’t file paperwork.¹

Some services still need prior authorization even through BlueCard. Inpatient surgeries, hospital stays, and outpatient surgical procedures are on that list. Before scheduling anything significant out of state, check your Evidence of Coverage or call the customer service number on your card.¹

Emergency and Urgent Care While Traveling

Every Blue Shield of California plan covers emergency and urgent care outside the service area. In a life-threatening situation, call 911 or go to the nearest hospital, and get authorization as soon as it is reasonably possible after the fact.¹

HMO members should know the follow-up limits. Blue Shield HMO authorization is required for more than two follow-up outpatient visits after an emergency or urgent visit, and any follow-up involving surgery or an inpatient stay also needs approval. The plan may tell you to return to your primary care physician in California rather than continue out-of-area care.³

If you’re on an HMO and you self-refer for routine or elective care out of state without authorization, expect the claim to be denied. Self-referrals for non-emergency, non-urgent services are explicitly excluded.³

Filling Prescriptions in Another State

Prescriptions aren’t part of BlueCard, but you don’t lose pharmacy access when you leave California. Blue Shield’s commercial pharmacy networks, Rx Ultra and Rx Spectrum, include retail chain, independent, grocery, and drug store pharmacies across the country. Fill your prescription at any participating pharmacy and pay your normal copay or coinsurance.⁸

On Rx Spectrum, preferred pharmacies such as CVS, Costco, and Albertsons-affiliated stores (Safeway, Vons, and Pavilions) carry lower cost-sharing. Non-preferred pharmacies are still in network but cost more. For maintenance medications, Small Business and most Large Group members can get extended supplies at any participating network pharmacy or by home delivery.⁸

Blue Shield recommends filling prescriptions before you leave and carrying copies of them with you.⁹

Long Stays Outside California: The Away From Home Care Program

HMO members and their dependents who will be outside California for an extended period have a specific option beyond emergency and urgent care. The Away From Home Care program enrolls you as a “guest” in a local Blue Cross Blue Shield HMO where you’re temporarily staying, giving you access to that host plan’s providers and benefits.¹

To qualify, you must be living outside your service area for at least 90 consecutive days and keep a permanent address in California. Eligible situations include:

A dependent living away at school. Student guest memberships take effect in September, last a year, and renew with a new application.
Long-term travel of at least 90 but no more than 180 consecutive days, when you intend to return home.
A member court-ordered to provide coverage for a dependent living in another state. There’s no time limit on this category, but it is reviewed each year.
Retirees with dual residences and workers on extended out-of-state assignments.

You have to live in the service area of a participating host Blue Cross Blue Shield HMO to use the program, and the benefits you receive will be the host plan’s, which can differ from your Blue Shield of California benefits. To check availability and start enrollment, call (800) 622-9402.¹⁰¹

For anything shorter than 90 days, use BlueCard for emergency or urgent needs instead.¹⁰

Telehealth While Traveling

Teladoc Health is available to Blue Shield members away from home, including on vacation or business trips. It offers 24/7 phone and video access to board-certified physicians for non-emergency issues. What you pay depends on your plan and can range from $0 to a standard office-visit copay; members on high-deductible plans may pay the full provider rate until the deductible is met. Teladoc is governed by state licensing rules and isn’t available in every state.¹¹

Filing a Claim for Out-of-State Care

See a BlueCard-participating provider and the claim is filed for you. See a non-participating provider and you may have to pay at the visit and submit for reimbursement.¹

You can file through the Blue Shield web portal, the mobile app, or by mail. For care received outside California, the form is the Subscriber Claim Form for Services Received Outside California (Form CLM14850-BC). Claims must be submitted within one year of the service date, and Blue Shield processes complete claims within 30 business days.¹²¹³

Traveling internationally and can’t find a BlueCard provider? Pay out of pocket and submit for reimbursement with an itemized bill that shows the services, the patient’s name, the provider information, and the cost in local currency. Submit through the member portal or the Blue Cross Blue Shield Global Core website.⁹

If You’re Moving, Not Just Traveling

Blue Shield of California individual and family plans require California residency. That means you have not established a permanent residence outside the state and you intend to live in California at least 180 days a year. Dependents ages 18 to 26 can live outside California for reasons such as college and stay eligible.¹⁴

If you permanently move out of California, Blue Shield can cancel coverage upon written notice. Losing coverage this way is a qualifying life event, so you can enroll in a new plan in your destination state during a special enrollment period. For employer-sponsored HMO members, moving out of the service area is likewise a termination event, though your employer may offer an out-of-state alternative if one exists.¹⁵¹⁶

1
Blue Shield of California. Access to Coverage
2
Blue Shield of California. Your Care Options
3
Blue Shield of California. Out-of-Area Services HMO Benefit Guidelines
4
Blue Shield of California. EPO Evidence of Coverage Benefit Booklet
5
Blue Shield of California. Provider Manual Appendix 5
6
Teamsters Local 1932. Trio HMO FAQ
7
Blue Shield of California. BlueCard FAQs
8
Blue Shield of California. Our Pharmacy Network
9
Blue Shield of California News. Traveling Soon
10
Word and Brown. Away From Home Care Program Flyer
11
Blue Shield of California. Teladoc Health
12
Blue Shield of California. Claim Forms
13
Blue Shield of California. Claims Payment Policy
14
Blue Shield of California. Special Enrollment Period Checklist and Residency Policy
15
Blue Shield of California. Application Eligibility and Underwriting Process Guide
16
Blue Shield of California. HMO Provider Manual Section 3