Blue Access for Employers

Frequently Asked Questions about
HMO Blue®



How does the HMO Blue Plan work?

With the HMO Blue Plan, each of your employees chooses a primary care provider (PCP) from our large statewide network of providers. The PCP is responsible for coordinating all health care and will be the physician who comes to know the employee's health care needs the best. Your employees must choose a PCP when they enroll. The PCP/patient relationship is one of the most important aspects of the HMO plan.

Predictable copayments are another important feature of HMO plans. A copayment is the amount members pay for most kinds of health care services. Check your Summary of Benefits for copayment amounts. Your employees do not have to meet a deductible and do not have to fill out claim forms when visiting participating providers.

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Will my employees have a choice of physicians?

We have PCPs in almost every county in the state and a wide selection of specialists in our HMO network. Each family member covered by this plan can select his or her own PCP. To see if a physician is in our network, check the online Provider Finder®. Members can select a new PCP at any time by calling Customer Service. The change may take 2-3 business days to process.

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Why is it important for my employees to get to know their primary care provider (PCP)?

A member's PCP will become the physician who knows that member best – his or her medical history and present state of health. This familiarity allows the PCP to make the best decisions when the member needs medical care, especially during an emergency. The PCP can also help coordinate visits to specialists.

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What if an employee is sick and his or her PCP is not available?

HMO participating providers are familiar with the services that need preauthorization and will handle the details for our members. However, if members want to coordinate their own care, they should familiarize themselves with the services listed as needing preauthorization in the Benefit Booklet. If a member is admitted as an inpatient, receives any of those services listed in the booklet as needing preauthorization, or visits a provider that is not in our provider network, the member will need to make sure preauthorization has been received from your HMO plan – or coverage will be denied.

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How does an employee change his or her PCP?

If a member would like to change PCPs, he or she should contact Customer Service using the toll-free number printed on the back of the member ID card.

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What happens when an employee's PCP leaves the network?

If a member's PCP leaves the network, the member will be notified. For information about selecting a new PCP, your employees should contact Customer Service using the toll-free number printed on the back of the member ID card.

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When do my employees need preauthorization?

HMO participating providers are familiar with the services that need preauthorization and will handle the details for our members. However, if members want to coordinate their own care, they should familiarize themselves with the services listed as needing preauthorization in the Benefit Booklet. If a member is admitted as an inpatient, receives any of those services listed in the booklet as needing preauthorization, or visits a provider that is not in our provider network, the member will need to make sure preauthorization has been received from your HMO plan – or coverage will be denied.

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Do my employees need a referral before seeing a specialist?

No, members do not need a referral to see an in-network specialist. However, we recommend they see their PCPs. The member's PCP is best qualified to coordinate all his or her medical care, including visits to specialists. Services received from out-of-network specialists are not covered.

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What if an employee or an employee's dependent temporarily lives out-of-state?

Subscribers living outside the HMO Blue service area for at least three months and no more than six months can become the "guest" of an affiliated HMO (where available), receiving benefits from the Host Plan. Dependents are also eligible for a guest membership and may renew membership after six months. See more information about the Away From Home Care® program.

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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 (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
copayment
The member pays this amount for a generic drug.
Tier 2
copayment*
The member pays this amount for a brand-name drug that is on our drug list when no generic is available.
Tier 3
copayment*
The member pays this amount for a brand-name drug that is not on our drug list or when receiving a preferred specialty drug**.
Tier 4
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.

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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 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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Learn More About HMO Blue

Overview
Benefit Information
Away From Home Care

 

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