• How does the BlueNet Plan work?
• What is a PPO Primary Provider (PPP)?
• The Summary of Benefits lists "Specialty Physician Services." What is a specialist?
• Why are there separate charges for a visit to a provider?
• What are the out-of-pocket costs for an emergency room visit?
• Is acupuncture covered?
• Is chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• What if my employees have questions about their benefits?
How does the BlueNet Plan work?
BlueNet does not require your employees to choose a primary care physician (PCP), or to obtain referrals to see a specialist. BlueNet members use BCBSNM Preferred Providers (in-network providers) to receive covered benefits and cost savings of the plan. To obtain benefits under BlueNet, members must use our Preferred Providers (except in an emergency).
What is a PPO Primary Provider (PPP)?
A PPO Primary Provider (PPP) is a Preferred Provider in one of the following medical specialties: Family Practice, General Practice, Internal Medicine, Obstetrics/Gynecology, Gynecology, or Pediatrics. PPPs do not include physicians specializing in any other fields such as Obstetrics only, Geriatrics, Pediatric Surgery, or Pediatric Allergy. When a member sees a PPP for an office visit, he or she pays a copayment (the deductible is waived). To find a PPP, members can check the printed Network Directory, search our Provider Finder®, or call Customer Service at the number on the back of the BCBSNM member ID card.
The Summary of Benefits lists "Specialty Physician Services." What is a specialist?
A specialist is a health care professional whose practice is limited to a certain branch of medicine such as specific procedures, age categories of patients, specific body systems, or certain types of diseases. A PPO specialist has a Preferred Provider contract with his or her BCBS Plan and is not a "PPP" as defined above. A PPO specialist does not include hospitals or other treatment facilities, pharmacies, equipment suppliers, ambulance companies, or similar ancillary health care service providers.
Why are there separate charges for a visit to a provider?
The member always pays an office visit copayment. There may be separate charges for any therapies or diagnostic tests performed during or as a result of the visit, and these charges are based on type of service and place of service (e.g., surgery performed in a provider's office or X-rays at an outpatient facility). The member may be responsible for paying additional coinsurance and deductible for these services. Please check your Benefit Booklet for more information.
What are the out-of-pocket costs for an emergency room visit?
The Emergency Room copayment covers both facility and provider charges. Your employees can see the Benefit Booklet for more information about covered emergency services.
This plan does not cover acupuncture except when used as an anesthetic during a covered surgical procedure; the acupuncture must be administered by a licensed provider. See your Summary of Benefits and Benefit Booklet for more information.
Chiropractic services are covered only when: 1) necessary for the treatment of an illness or injury, 2) administered by a licensed provider, and 3) used as short-term rehabilitation (all of these three conditions must apply). If an employee has a consultation with a licensed provider, such as to check on progress, he or she will pay an office visit copayment. When therapy or spinal manipulation is performed, the employee will pay deductible and coinsurance (benefits are limited as stated on the Summary of Benefits under "Short-Term Rehabilitation"). The employee may be charged for an office visit, therapy, or both, depending on the nature of the visit.
Is outpatient surgery covered?
Yes, a variety of technical procedures for treatment or diagnosis of anatomical disease or injury are covered, such as microsurgery (use of scopes); laser procedures; treatment of fractures and dislocations; and endoscopic examinations. Benefits for surgical services also include usual and related local anesthesia, and pre- and post-operative care, including recasting. Outpatient procedures generally require prior authorization. See your Summary of Benefits and Benefit Booklet for more information.
Note: Outpatient or observation services and related physician or other professional provider services are also covered for the treatment of illness or accidental injury, depending on the type of service received or if there are special circumstances (for example, an emergency).
How does the prescription drug plan work?
You have chosen one of the prescription drug plans below for your employees. Please refer to your Prescription Drug Plan Rider or BCBSNM member ID card to confirm which plan you selected.
Percent/Coinsurance Drug Plan
The copayment for prescription drugs purchased through this drug plan is 25 percent of the covered charge for generic drugs and 50 percent of the covered charge for brand-name drugs. If the percentage of the covered charge falls between the minimum/maximum copayment, the member will pay the actual percentage amount.
| Program | Percentage Member Pays | Minimum Amount | Maximum Amount |
| Retail Pharmacy: Up to a 30-day supply or 180 units, whichever is less. | |||
| Generic drug | 25% | $20 | $75 |
| Brand-name drug | 50% | $40 | $125 |
| PrimeMail Pharmacy Mail-Order Service: Up to a 90-day supply or 540 units, whichever is less. | |||
| Generic drug | 25% | $40 | $150 |
| Brand-name drug | 50% | $80 | $250 |
| Prior-approved enteral nutritional products and special medical foods. | 50% | N/A – member pays 50% | N/A – member pays 50% |
The copayment will never exceed the maximum copayment listed. Prescription copayments are applied to an annual out-of-pocket limit of $2,500. When this limit is reached, the drug plan pays 100 percent of covered charges for the remainder of the calendar year. The out-of-pocket limit, which includes coinsurance and copayments, is separate from the medical plan’s out-of-pocket limit. Advise your employees to fill prescriptions at a participating pharmacy (see the Network Directory or search the Provider Finder®) or through the PrimeMail Pharmacy Program, our prescription drug mail-order service. Coverage is always subject to the limitations of your group's health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See your Prescription Drug Plan Rider for details, limitations, and exclusions.
The BCBSNM Drug List does not apply to the 25/50 Percent Prescription Drug Plan.
4-Tier Drug Plan
The 4-Tier prescription drug plan allows members to get a prescription drug even if it's not on the BCBSNM Drug List and to get a brand-name drug even when a generic-equivalent is available. The copayment is based on whether the member is receiving a generic drug or a brand-name drug AND whether the drug is on our Drug List.
Prescription drug payments are based on the following tier structure for a 30-day supply or 120 units, whichever is less.
| Tier 1=lowest copayment | The member pays this amount for a generic drug. |
| Tier 2=middle copayment* | The member pays this amount for a brand-name drug that is on our drug list when no generic is available. |
| Tier 3=highest copayment* | The member pays this amount for a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug | The member pays 15% of covered charges or up to a $250 maximum copayment per prescription. |
*If a member or a member's doctor prefers that he or she receive a brand-name drug when a generic equivalent is available, the member will pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
Under the PrimeMail Pharmacy Program, you can select a plan that allows your employees to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Advise your employees to have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program. Check the printed Network Directory for participating pharmacies or search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of your group's health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.
See your Prescription Drug Plan Rider for details, limitations, exclusions, and Specialty Pharmacy Program information.
3-Tier Drug Plan
The 3-Tier prescription drug plan has three levels of copayments. Members pay the Tier 1 copayment (the lowest) for a generic drug; the Tier 2 copayment for a brand-name formulary drug (if a generic is not available); and the Tier 3 copayment for a covered drug that is not on the BCBSNM drug list. Members pay additional costs if receiving a brand-name drug when a generic equivalent is available (even if the member’s doctor requests the brand-name drug). Advise your employees to have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program. Members can check the printed Network Directory for participating pharmacies or search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of your group’s health care plan and some drugs are not covered. For some medications, prior approval requirements, generic substitution, or quantity limits may apply. See your Prescription Drug Plan Rider for details, limitations, and exclusions.
What if my employees have questions about their benefits?
BCBSNM's customer service representatives are available to answer your employees' questions 6 a.m. to 10 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT on Saturdays and holidays. If a member calls after hours, he or she can leave a message and we will return the call by the next business day. Members should call the toll-free number printed on the back of the member ID card and should have the ID card available when calling. They may also email questions to BCBSNM Customer Service.
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Overview
Benefit Information
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