• How does the Blue PPO 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?
• How does my prescription drug plan work?
• What if I have questions about my benefits?
How does the Blue PPO Plan work?
Blue PPO 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. Some services are only covered if you receive them from a Preferred Provider. For most services, you will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges).
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, psychotherapeutic services and adult preventive services must be received from Preferred Providers in order 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 $20 copayment. To find a PPP, search the Provider Finder®. You may also call Customer Service at the number on the back of your 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. You will pay deductible and coinsurance for other related 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. You will also pay deductibles and coinsurance for these services.
How does my 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. Search the Provider Finder® to locate a participating 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. Search the Provider Finder® to locate a participating 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 my 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 your questions to BCBSNM Customer Service.
Learn More About Blue PPO
Overview
Benefit Information
