If there are any discrepancies between these FAQs and the Benefit Booklet, the terms of the booklet will govern in all cases. You may review the Benefit Booklet or obtain a copy from your employer's benefit office.
• How does my health plan work?
• Am I covered for the same services even if I get care from a Nonpreferred Provider?
• Do I have coverage for preventive services?
• How does my prescription drug plan work?
• What if I have questions about my medical plan benefits?
Your New Mexico Public Schools Insurance Authority (NMPSIA) Dual Option PPO health plan allows you to see the providers you want to see. You can choose either the High Option Plan or the Low Option Plan. For these PPO Plans, you 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). You'll generally pay more if you receive services from Nonpreferred Providers, but it is your choice to receive most covered health care services from any licensed provider. Transplant services are only covered if you receive them from a Preferred Provider.
If you have the High Option Plan, you do not need to meet a deductible for services from Preferred Providers. You will pay a copayment for most services you receive from Preferred Providers. Generally, for services from Nonpreferred Providers, you will need to first meet a deductible and then pay 30 percent coinsurance.
If you have the Low Option Plan, you will first need to meet a deductible before the Plan pays for most services from both Preferred and Nonpreferred Providers. Generally, after the deductible is met, you will pay 25 percent coinsurance for most services from Preferred Providers and 50 percent coinsurance for most services from Nonpreferred Providers. For office visits to Preferred Providers you will pay a $25 copayment. Any services performed during or as a result of the office visit are subject to deductible and coinsurance amounts.
Am I covered for the same services even if I get care from a Nonpreferred Provider?
No. For example, you must receive transplant services from Preferred Providers for the services to be covered. Also, some benefits for services are limited if you receive them from Nonpreferred Providers, but are not limited if received from Preferred Providers.
Do I have coverage for preventive services?
If you receive Preventive Services from Preferred Providers, both the High Option and Low Option pay 100 percent of the charges. If you receive preventive services from Nonpreferred Providers, High Option Plan members pay 30 percent coinsurance and Low Option Plan members pay 50 percent coinsurance. You do not need to meet a deductible for covered Preventive Services. Preventive services include: routine adult physicals and gynecologic exams, well-child care, routine vision or hearing screenings through age 17; related testing including routine Pap tests, mammograms, cholesterol tests, urinalysis; and immunizations.
How does my prescription drug plan work?
Blue Cross and Blue Shield of New Mexico does not administer your prescription drug plan – it is administered by Catalyst Rx. For questions about your prescription drug plan, call Catalyst Rx at 1-866-611-5948 or visit www.catalystrx.com*.
What if I have questions about my medical plan benefits?
BCBSNM's customer service representatives are available to answer your questions 6 a.m. to 8 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT on Saturdays and holidays. If you call after hours, you can leave a message and we will return your call by the next business day. Call the NMPSIA Designated Service Unit toll-free at 1-888-9NMPSIA (1-888-966-7742); the number is also printed on the back of your member ID card. Please have your ID card available when you call. You may also email your questions to BCBSNM Customer Service.
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