Blue Access for Members
Individual & Family:

Change to Your PPO Plan Starting in 2025

Thank you for your membership with Blue Cross and Blue Shield of Illinois. We value your trust in us and the health care coverage we provide.

We’d like to highlight an important change to your policy.

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What is Changing?

As of January 1, 2025, non-emergency or non-urgent care out of state beyond the counties that border Illinois will not be a covered benefit under your plan.

  • What this means:
    • Coverage for non-emergency or non-urgent care outside your plan’s service area or border counties will be available only if adequate care is not available in your plan’s service area.
    • If a service you need is not available in your plan’s service area, coverage may be available if you ask for a waiver in advance and it is approved.

    To find in-network care, log in to Blue Access for MembersSM or visit our Provider Finder® tool.

  • When you will need an approved waiver:

    You will need an approved waiver from BCBSIL before you receive non-emergency or non-urgent care:

    • From a provider outside Illinois or the counties that border Illinois (“contiguous counties”). This includes both in-network and out-of-network providers.
    • From out-of-network providers in counties that border Illinois.

    To ask for a waiver for services beginning January 1, 2025, call Customer Service at the number on your member ID card.

  • For more information:

    Please refer to the "Answers to Questions You May Have" section of this page to see the counties that are contiguous to Illinois as well as more information on out-of-service-area waivers.

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Important to Remember

  • Non-emergency or non-urgent out-of-state care beyond the border counties will not be covered unless you obtain an out-of-service-area waiver.
  • A waiver for otherwise covered services will be approved only if the services are not available in the plan's service area.
  • A waiver will be denied if adequate care is available in Illinois or its border counties. You may be redirected to available local, in-network services.

If you do not receive an approved waiver in advance of receiving non-urgent or non-emergency care from providers outside Illinois and its contiguous counties, the services will not be covered under your plan. You will be responsible for the full cost. As always, if you are facing a medical emergency, call 911 or go to the nearest emergency room.

How to Request a Waiver

To request a waiver, call Customer Service at 1-800-538-8833. An agent will need the following information, so it may be helpful to speak with your doctor ahead of calling:

  • Provider name, address and phone number
  • Provider type
  • Provider number/NPI (10-digits)
  • Provider tax ID (9-digits with a hyphen after the 2nd digit)
  • Diagnosis code
  • Estimated number of visits
  • First date of service (if your service date isn't on or after 1/1/2025, the waiver will not be considered)
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What Is Not Changing?

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Access to emergency care.

You will still be able to get emergency and urgent care nationwide without the need for a waiver.

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Finding care.

You can still find in-network providers through Blue Access for Members under "Find Care."

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Freedom to choose.

You continue to be free to visit a range of in-network providers, specialists, and hospitals throughout Illinois and its contiguous counties.

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Benefits.

You will receive benefits that are similar to the benefits that are part of your plan today. You can choose to go to an out-of-network provider or facility within Illinois without a waiver. If you do, however, you may pay more for your care than if you were to stay in network.

Are There Areas Where I Won’t I Need a Waiver for Non-Emergency or Non-Urgent Care?

If you're a Blue Choice Preferred PPOSM member:

Review a map of included counties if you're a Blue Choice Preferred PPO member.

You won’t need a waiver for providers in Illinois or for providers who are in network with a Blue Cross and Blue Shield Plan in the border counties below:

  • Indiana: Benton, Gibson, Knox, Lake, Newton, Posey, Sullivan, Vermillion, Vigo, Warren
  • Iowa: Clinton, Des Moines, Dubuque, Jackson, Lee, Louisa, Muscatine, Scott
  • Kentucky: Ballard, Crittenden, Livingston, McCracken, Union
  • Missouri: Cape Girardeau, Clark, Jefferson, Lewis, Lincoln, Marion, Mississippi, Perry, Pike, Ralls, Scott, St. Charles, St. Louis, City of St. Louis, Ste. Genevieve
  • Wisconsin: Grant, Green, Kenosha, Lafayette, Rock

If you're a MyBlue Plus POSSM member:

Review a map of included counties if you're a MyBlue Plus POS member.

You won’t need a waiver for providers in Illinois or for providers who are in network with a Blue Cross and Blue Shield Plan in the border counties below:

  • Indiana: Benton, Gibson, Knox, Lake, Newton, Posey, Sullivan, Vermillion, Vigo, Warren
  • Iowa: Clinton, Des Moines, Dubuque, Jackson, Lee, Louisa, Muscatine, Scott
  • Kentucky: Ballard, Crittenden, Livingston, McCracken, Union
  • Missouri: Cape Girardeau, Clark, Jefferson, Lewis, Lincoln, Marion, Mississippi, Perry, Pike, Ralls, Scott, St. Charles, St. Louis, City of St. Louis, Ste. Genevieve
  • Wisconsin: Grant, Green, Kenosha, Lafayette, Rock

Answers to Questions You May Have

  • I’m currently receiving care from a provider who’s outside Illinois and not in a contiguous county. What should I do?

    Certain conditions or situations that began before January 1, 2025, and require ongoing treatment may qualify for “continuity of care” or “transition of care” for a period of time. For example, you may qualify if you are currently going to a provider or facility outside Illinois and Illinois’ contiguous counties for:

    • An ongoing course of treatment for a serious and complex condition;
    • Institutional or inpatient care that began before January 1, 2025;
    • Non-elective surgery before January 1, 2025, including receiving ongoing postoperative care from the provider or facility related to the surgery;
    • Current pregnancy and/or an ongoing course of treatment for a current pregnancy; or
    • Ongoing treatment of an illness that was determined to be terminal.

    To find out more about continuity or transition of care and to see if you may qualify, call Customer Service at the number on your ID card. A health advocate will help you. You may also receive communications from us with more information.

  • I don’t qualify for continuity or transition of care. What does that mean for my care?
    • If the care you are receiving now is available in Illinois or from a provider contracted with the Blue Cross and Blue Shield Plan in a contiguous county, you will need to find care in Illinois or a contiguous county to receive benefits under your plan starting January 1, 2025.
    • If the care you are receiving is not available in Illinois or from a provider contracted with the Blue Cross and Blue Shield Plan in a contiguous county, you will need to get an approved waiver before any appointments scheduled in 2025 with the provider.

  • If I do need a waiver, how and when will I be informed the request has been approved?

    The waiver approval or denial will be provided within 7 days after we receive your request. It will be mailed through the United States Postal Service. Please note, waiver approval is not guaranteed.

  • What will be considered in determining whether a waiver will be granted?

    A review will be conducted to determine:

    • The location of the service being requested,
    • Whether the service being requested is available in Illinois,
    • Whether there is a Blue Cross and Blue Shield Plan where the service will be provided, and
    • Whether the provider is contracted with the Blue Cross and Blue Shield Plan where the service will be provided.

    A waiver may be granted to receive non-urgent or non-emergency care from:

    • Providers outside Illinois and its contiguous counties if the service being requested is not available in Illinois or from a provider contracted with a Blue Cross and Blue Shield Plan in its contiguous counties.
    • An out-of-network provider in a contiguous county if the service being requested is not available from an in-network provider in Illinois or its contiguous counties.

  • Do waivers expire?

    Waivers do expire. When a waiver expires depends on the service you receive.

  • Once I have an approved waiver, how many times may I see the provider?

    You may see the provider as many times as is medically necessary while the approved waiver is in effect.

  • If a waiver is denied, can I appeal?

    As with claims denial, you may appeal a waiver denial. You will receive information on how to appeal if your request is denied.

  • What if a provider is in Illinois but is not in my plan’s network?
    • You do not need a waiver to see any provider in Illinois.
    • If the provider is not in your plan’s network, you may have to pay any out-of-network cost sharing.
    • Keep in mind that any out-of-network cost sharing will be higher than if you went to an in-network provider.

  • What if I (or a covered dependent) reside part time outside Illinois?
    • If you wish to receive non-urgent or non-emergency care outside Illinois and its contiguous counties, you must get an approved waiver before receiving such care.
    • This plan change applies to “snowbirds,” students who attend school outside Illinois, and covered dependents who reside outside Illinois.