• How does my health plan work?
• Am I covered for the same services even if I get care from a Nonpreferred Provider?
• What is a PPO Primary Provider (PPP)?
• What services are covered under the PPP office visit copayment?
• 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 PNM Resources, Inc., health plan options let you see the providers you want to see. You have a choice of three levels of health plan options: Premium, Standard, and Value. Your out-of-pocket costs will generally be lower if you choose the Premium Plan. However, you will have lower premiums for both the Standard and Value plan options.
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. For most services, you will have a deductible to meet and then be responsible for paying coinsurance (a percentage of covered charges). Some services are only covered if you receive them from a Preferred Provider. Services that are subject to copayments instead of percentage coinsurance amounts are not subject to the deductibles.
Am I covered for the same services even if I get care from a Nonpreferred Provider?
No, some services are not covered if you receive them from Nonpreferred Providers. For example, you must receive psychotherapeutic services and transplants from Preferred Providers in order for the services to be covered. Your Benefits Guide will list some of these services in detail. Also, benefits for some services are limited if you receive them from Nonpreferred Providers, but are not limited if received from Preferred Providers.
What is a PPO Primary Provider (PPP)?
A Primary Preferred 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 you see a PPP for an office visit, you pay a set copayment rather than a percentage of the charges (the deductible is waived). The amount of the copayment is: Premium Option: $15, Standard Option: $20, Value option: $25. To find a PPP, search our online Provider Finder®. You may also call Customer Service at the number on the back of your ID card (1-888-PNM-BCBS or 1-888-766-2227) for help looking for a PPP. Your health plan does not require you to visit a PPP or get a referral from a PPP to see a specialist.
What services are covered under the PPP office visit copayment?
The PPP office visit copayment covers only the PPP's office visit. You will pay deductible and coinsurance for other services you 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. Related preventive testing – such as routine Pap tests, mammograms, cholesterol tests, urinalysis, and immunizations – is covered at 100% (up to $600 for preventive services), with no out-of-pocket cost for the member.
Do I have coverage for 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. If you receive Preventive Services from Preferred Providers, BCBSNM pays up to a $600 maximum for each member. After the $600 maximum is reached, services are subject to deductible and coinsurance. Preventive Services received from Nonpreferred Providers are subject to deductible and coinsurance.
How does my prescription drug plan work?
Your 3-Tier prescription drug plan allows you 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. You pay different amounts depending on if the prescription drug is a generic or a brand name and whether the drug is on the BCBSNM Drug List.
Prescription drug payments are based on the following tier structure for a 30-day supply or 120 units, whichever is less.
| Premium Option | Standard or Value Option | |
| Tier 1 = lowest copayment | You pay $7 when you receive a generic drug. | |
| Tier 2 = middle copayment | You pay $30 for a brand-name drug on our Drug List if no generic equivalent is available. | You pay $40 for a brand-name drug on our Drug List if no generic equivalent is available. |
| Tier 3 = highest copayment | You pay $50 for a brand-name drug that's not on our Drug List. | You pay $60 for a brand-name drug that's not on our Drug List. |
If you or your doctor prefer that you receive a brand-name drug when a generic equivalent is available, you'll pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
For commercially packaged items (such as inhalers, tubes of ointment, drug blister packs, insulin or boxes of test strips), you will pay the applicable copayment for each package, regardless of the days' supply the package represents. For example, if two inhalers are purchased under the Retail Pharmacy Program, two copayments will apply. Under the PrimeMail Pharmacy Program, your plan may allow you to receive up to three packages (a 90-day supply) via mail order for only 2 times the retail copayment, depending on your plan.
Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy prescription mail-order service. Search the online Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of your 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 my medical plan benefits?
BCBSNM Customer Service is available to answer your questions 6 a.m to 10 p.m. (Mountain Time), Monday through Friday, and 8 a.m. to 5 p.m. (Mountain Time), 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 PNM Resources Designated Service Unit toll-free at 1-888-PNM-BCBS (1-888-766-2227); 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 Customer Service.
