Frequently Asked Questions about
- How does the BluePPO Evolution Plan work?
- Are members covered for the same services even if they get care from a Nonpreferred Provider?
- What is a PPO Primary Provider (PPP)?
- How does the prescription drug plan work?
- What if members have questions about their benefits?
BluePPO Evolution is a Preferred Provider Organization (PPO) plan that lets members see the providers they want to see. They do not have to choose a primary care provider and do not need a referral to see a specialist. Providers are classified as "Preferred" (in-network) or "Nonpreferred" (out-of-network), and their choice of provider will determine the amount of their out-of-pocket costs. Members will pay a higher deductible and higher out-of-pocket costs if they visit Nonpreferred Providers, but it is their choice to receive most covered health care services from any licensed provider. For most services, members will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges).
Yes. However, they will pay a higher deductible and coinsurance. Also, benefits for some services are limited if they are received from Nonpreferred Providers, but are not limited if received from Preferred Providers. Smoking cessation is not covered out-of-network.
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 members see a PPP for an office visit, they pay a copayment. To find a PPP, members can search the Provider Finder®. They may also call Customer Service at the number on the back of their BCBSNM member ID card for help looking for a PPP.
Members may select one of the prescription drug plans below. BCBSNM members can refer to their ID card or the Prescription Drug Plan Rider to confirm which plan they have.
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, they will pay the actual percentage amount.
|Program||Percentage Members Pay||Minimum Amount||Maximum Amount|
|Retail Pharmacy: Up to a 30-day supply or 180 units, whichever is less.|
|PrimeMail Pharmacy Mail-Order Service: Up to a 90-day supply or 540 units, whichever is less.|
|Prior-approved enteral nutritional products and special medical foods.||50%||N/A – members pay 50%||N/A – members pay 50%|
The copayment will never exceed the maximum copayment listed. The prescription copayments are applied to an annual out-of-pocket limit of $2,500. When this limit is reached, the drug plan pays 100% 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. Members should have prescriptions filled at a participating pharmacy (search the Provider Finder) or through the PrimeMail Pharmacy mail-order service. Coverage is always subject to the limitations of the health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See the 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 plans allow 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 they are 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.
|The member pays this amount for a generic drug.|
|The member pays this amount for a brand-name drug that is on our drug list when no generic is available.|
|The member pays this amount for a brand-name drug that is not on our drug list or when receiving a preferred specialty drug**.|
copayment for non-preferred specialty drugs**
|The member pays 15% of covered charges or up to a $250 maximum copayment per prescription for non-preferred specialty drugs.|
* If members or their doctor prefer that they receive a brand-name drug when a generic equivalent is available, they will pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
** Specialty pharmacy drugs are used to treat serious and/or chronic conditions such as multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. These medications are typically injectable and can be administered by a patient or family member. Members must use a contracting specialty network pharmacy to fill these specific prescriptions.
Under the PrimeMail Pharmacy Program, the plan may allow members to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Members should have their prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. They can search the Provider Finder to locate a participating pharmacy in New Mexico. Coverage is always subject to the limitations of the health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.
See the Prescription Drug Plan Rider for details, limitations, exclusions, and Specialty Pharmacy Program information.
3-Tier Drug Plan (For groups 51+ only)
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 they receive a brand-name drug when a generic equivalent is available (even if their doctor requests the brand-name drug). Members should have their prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. They can search the Provider Finder to locate a participating pharmacy in New Mexico. Coverage is always subject to the limitations of the health care plan and some drugs are not covered. For some medications, prior approval requirements, generic substitution, or quantity limits may apply. See the Prescription Drug Plan Rider for details, limitations, and exclusions.
BCBSNM's customer service representatives are available to answer questions 6 a.m. to 8 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT on weekends and holidays (closed Thanksgiving and Christmas Day). If members call after hours, they can leave a message and we will return their call by the next business day. Members should call the toll-free number printed on the back of their member ID card and they should have their ID card available when they call. They may also contact customer service with a secure message through Blue Access for MembersSM
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