• How does the BlueNet "H" EPO Plan work?
• What is a PPO Primary Provider (PPP)?
• The Summary of Benefits lists "Specialty Physician Services." What is a specialist?
• Which provider network do I use with my BlueNet "H" EPO Plan?
• Why are there separate charges when I visit a provider?
• What are my out-of-pocket costs in an emergency room?
• Are acupuncture and chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• What if I have questions about benefits?
How does the BlueNet "H" EPO Plan work?
BlueNet "H" EPO does not require a deductible be met. Members are responsible for set copayments for certain services. BlueNet "H" does not require members to choose a primary care provider (PCP), or to obtain referrals to see a specialist. BlueNet "H" members use BCBSNM Preferred Providers (in-network providers) to receive covered benefits and cost savings of the plan. To obtain benefits under this plan, you 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 you see a PPP for an office visit, you pay a copayment (the deductible is waived). To find a PPP, search our Provider Finder®. You may also call Customer Service at the number on the back of your BCBSNM member ID card for help finding a PPP.
The Summary of Benefits lists "Specialty Physician 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.
Which provider network do I use with my BlueNet "H" EPO Plan?
You will use the Blue Cross and Blue Shield of New Mexico PPO provider network to access contracted doctors, hospitals, and other health care professionals within New Mexico. BlueNet "H" EPO members also have access to BlueCard® PPO providers when outside New Mexico.
Why are there separate charges when I visit a provider?
Members always pay an office visit copayment. There may be separate charges for any therapies, diagnostic tests, MRIs, and PET scans 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 copayments for these services. They can check the Benefit Booklet for more information.
What are my out-of-pocket costs in an emergency room?
The Emergency Room copayment covers both facility and provider charges. See your Summary of Benefits for more information about covered emergency services.
Are acupuncture and chiropractic care covered?
This plan covers acupuncture treatment and chiropractic services. This alternative therapy benefit is limited to $1500 per year for both acupuncture and chiropractic care. See the Summary of Benefits and Benefit Booklet for more information.
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 nonroutine colonoscopies. 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. See your 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?
You have one of the prescription drug plans below. Please refer to your BCBSNM member ID card or your Prescription Drug Plan Rider to confirm which plan you have.
Percent/Coinsurance Drug Plan
Your 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, you will pay the actual percentage amount.
| Program | Percentage You 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 – you pay 50% | N/A – you pay 50% |
Your copayment will never exceed the maximum copayment listed. Your 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. Be sure to have your prescriptions filled at a participating pharmacy (search the Provider Finder®) or through the PrimeMail Pharmacy mail-order service. Coverage is always subject to the limitations of your health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See your 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 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 this amount when you receive a generic drug. |
| Tier 2=middle copayment* | You pay this amount when you receive a brand-name drug that is on our drug list and no generic is available. |
| Tier 3=highest copayment* | You pay this amount when you receive a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug | You pay a copay or percentage based on your plan benefits. |
*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, your plan may allow you to 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. For participating pharmacies, 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.
3-Tier Drug Plan
The 3-Tier prescription drug plan has three levels of copayments. You 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. You pay additional costs if you receive a brand-name drug when a generic equivalent is available (even if your doctor requests the brand-name drug). Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. For participating pharmacies, search the 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 your Prescription Drug Plan Rider for details, limitations, and exclusions.
What if I have questions about 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 weekends and holidays (closed Thanksgiving and Christmas Day). 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 questions to BCBSNM Customer Service.
Learn More About BlueNet "H" EPO
Overview
Benefit Information
Provider Information
