• How does the Blue PPO Plan work?
• Are my clients covered for the same services even if they get care from a Nonpreferred Provider?
• What is a PPO Primary Provider (PPP)?
• What services are covered under the PPP office visit copayment?
• How does the prescription drug plan work?
• What if I have questions about group plans?
How does the Blue PPO Plan work?
Blue PPO is a Preferred Provider Organization (PPO) plan that lets your clients 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. Your clients 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. Some services are only covered if they are received from a Preferred Provider. For most services, they will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges).
Are my clients covered for the same services even if they get care from a Nonpreferred Provider?
No, some services are not covered if they are received from Nonpreferred Providers. For example, psychotherapeutic services and adult preventive services must be received from Preferred Providers in order to be covered. The Benefit Booklet lists these services in detail. Also, benefits for some services are limited if they are received from Nonpreferred Providers, but are not limited if received from Preferred Providers.
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 $20 copayment. To find a PPP, your clients can check the printed Network Directory or 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.
What services are covered under the PPP office visit copayment?
The PPP office visit copayment covers only the PPP's office visit charge. Your clients will pay deductible and coinsurance for other related services they receive during the visit (such as an immunization) or for services that are ordered by the PPP during the visit (such as lab work), and for services from other Preferred Providers or from Nonpreferred Providers. They will also pay deductibles and coinsurance for these services.
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. Their 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 will 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 their doctor requests the brand-name drug). Members should have 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 group plans?
For more information about our plans for groups, please contact BCBSNM Customer Service toll-free at (800) 432-0750 or email us.
Learn More About Blue PPO
Overview
Benefit Information
Back to main Health Plans page | Back to main Producer page
