• How does the BlueChoice 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/exam copayment?
• How does my prescription drug plan work?
• What if I have questions about my benefits?
How does the BlueChoice Plan work?
BlueChoice is a Preferred Provider Organization (PPO) plan that lets you see the providers you want to see. 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), and your choice of provider will determine the amount of your out-of-pocket costs. You will pay a higher deductible and higher out-of-pocket costs if you visit Nonpreferred Providers, but it is your choice to receive most covered health care services from any licensed provider. For most services, you will first meet a deductible, and then you will be responsible for paying coinsurance (a percentage of covered charges).
Note: BlueChoice does not cover maternity services, mental health services, or alcoholism and drug abuse treatment.
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 physical therapy services from Preferred Providers to be covered. Your Benefit Booklet lists 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 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 you see a PPP for an office visit, you pay a copayment. To find a PPP, check the printed Network Directory. Members may also call Customer Service at the number on the back of their BCBSNM member ID card for help finding a PPP.
What services are covered under the PPP office visit/exam copayment?
The PPP office visit copayment covers only the PPP office visit. The PPP must be contracted as a PPP in our Preferred Network. 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.
How does my prescription drug plan work?
The 4-Tier prescription drug plans allow 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. Your copayment is based on whether you 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 | You pay $10 when you receive a generic drug. |
| Tier 2 = middle copayment* | You pay $35 when you receive a brand-name drug that is on our drug list. |
| Tier 3 = highest copayment* | You pay $75 when you receive a brand-name drug that is not on our drug list and no generic is available. |
| Tier 4 = specialty drug | You pay 15% of covered charges or up to a $250 maximum copayment per prescription. |
*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.
Under the PrimeMail Pharmacy Program, you may receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. 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 your 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.
What if I have questions about my benefits?
BCBSNM's customer service representatives are available to answer your questions 6 a.m. to 10 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 toll-free number 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.
Learn More About BlueChoice
Overview
Benefit Information
Downloadable Forms
