• How does the BlueNet Plan work?
• What is a PPO Primary Provider (PPP)?
• The Summary of Benefits lists "Specialty Physician Office Services." What is a specialist?
• Why are there separate charges when my clients visit a provider?
• What are the out-of-pocket costs in an emergency room?
• Is acupuncture covered?
• Is chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• What if I have questions about group plans?
How does the BlueNet Plan work?
BlueNet does not require members 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 your clients see a PPP for an office visit, they pay a copayment (the deductible is waived). To find a PPP, your clients can check the printed Network Directory or search our Provider Finder®. They may also call Customer Service at the number on the back of their BCBSNM member ID card for help finding a PPP.
The Summary of Benefits lists "Specialty Physician Office 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/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 when my clients visit a provider?
Members always pay 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). Members may be responsible for paying additional coinsurance and deductible for these services. They can check the Benefit Booklet for more information.
What are the out-of-pocket costs in an emergency room?
The Emergency Room copayment covers both facility and provider charges. Your clients can see the Summary of Benefits 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 the Summary of Benefits and Benefit Booklet for more information.
Chiropractic services (referred to as "spinal manipulation" in the Summary of Benefits and Benefit Booklet) 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 your clients have a consultation with a licensed provider, such as to check on their progress, they will pay an office visit copayment. When therapy is performed, they will pay deductible and coinsurance. Your clients may be charged for an office visit, therapy, or both, depending on the nature of the visit. Benefits for spinal manipulation are limited as specified in the Summary of Benefits and Benefit Booklet.
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. Your clients can see the 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?
Your clients 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. | |||
| 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 – 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 their prescriptions filled at a participating pharmacy (see the Network Directory or 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.
| Tier 1=lowest copayment | Members pay this amount when they receive a generic drug. |
| Tier 2=middle copayment* | Members pay this amount when they receive a brand-name drug that is on our drug list and no generic is available. |
| Tier 3=highest copayment* | Members pay this amount when they receive a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug | Members pay a copay or percentage based on the plan benefits. |
*If members or their doctor prefer that they receive a brand-name drug when a generic equivalent is available, they'll pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
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 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 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
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 the 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 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 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.
What if I have questions about benefits?
For more information about our plans for groups, please contact BCBSNM Customer Service toll-free at (800) 432-0750 or email us.
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Benefit Information
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