Frequently Asked Questions about
Blue PPO OptionsSM
- How does the Blue PPO Options Plan work?
- Are my employees covered for the same services even if they get care from a nonpreferred provider?
- How does the prescription drug plan work?
- What if my employees have questions about their benefits?
Blue PPO Options is a Preferred Provider Organization (PPO) plan that lets your employees 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 the choice of provider will determine the amount of out-of-pocket costs. Members do not pay a deductible if they visit Preferred Providers. Also, for most services from Preferred Providers, members will pay a predictable copayment. For most services from a Nonpreferred Provider, members will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges). Some services are only covered if received from a Preferred Provider. Members can see the licensed provider of their choice for most covered health care services.
No. Some services are not covered if received from Nonpreferred Providers. For example, psychotherapeutic services and preventive services must be received from Preferred Providers in order to be covered. Your Benefit Booklet lists these services in detail. Also, benefits for some services are limited if received from Nonpreferred Providers, but are not limited if received from Preferred Providers.
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.|
|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 – 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 (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.
|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 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.
** 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, 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. Search the Provider Finder to locate a participating 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 (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 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 search the Provider Finder to locate a participating 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.
BCBSNM's customer service representatives are available to answer your employees' 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 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 contact customer service with a secure message through Blue Access for MembersSM.
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