• How does the HMO Blue Plan work?
• Will I have a choice of physicians?
• Why is it important to get to know my PCP?
• What if I'm sick and my PCP is not available?
• How do I change my primary care physician (PCP)?
• What happens if my PCP or medical group leaves the network?
• When do I need prior authorization?
• Do I need a referral before seeing a specialist?
• What if my dependents or I temporarily live out of state?
• How does my prescription drug plan work?
• What if I have questions about my benefits?
How does the HMO Blue Plan work?
With the HMO Blue Plan, you choose a primary care physician (PCP) from our large, statewide network of physicians. Your PCP will be responsible for coordinating all of your health care and will be the physician who comes to know you and your health care needs the best. You must choose a PCP when you enroll. The PCP/patient relationship is one of the most important aspects of the HMO plan.
Predictable copayments are another important feature of HMO plans. A copayment is the amount you pay for most kinds of health care services. Check your Summary of Benefits for your copayment amounts. You do not have to meet a deductible and do not have to fill out claim forms when visiting participating providers.
Will I have a choice of physicians?
We have PCPs in almost every county in the state and a wide selection of specialists in our HMO network. Each family member covered by this plan can select his/her own PCP. To see if your physician is in our network, check the online Provider Finder®. You can select a new PCP at any time by calling Customer Service. The change may take 2-3 business days to process.
Why is it important to get to know my PCP?
Your PCP will become the physician who knows you best – your medical history and your present state of health. This familiarity allows your PCP to make the best decisions when you need medical care, especially during an emergency. Your PCP can also help coordinate visits to specialists.
What if I'm sick and my PCP is not available?
Participating physicians have agreed to be accessible 24 hours a day for our members. Contact your PCP for advice on how to get care. If your PCP is unavailable, he or she will designate an alternate physician to provide the care or advice you need.
How do I change my primary care physician (PCP)?
If you would like to change your PCP, please contact Customer Service using the toll-free number printed on the back of your member ID card.
What happens if my PCP or medical group leaves the network?
If your PCP or medical group leaves the network, you will be notified. For information about selecting a new primary care physician, please contact Customer Service using the toll-free number printed on the back of your member ID card.
When do I need prior authorization?
Participating providers are familiar with the services that need prior authorization and will handle the details for you. However, if you want to coordinate your own care, you should familiarize yourself with the services listed as needing authorization in your Benefit Booklet. If you are admitted as an inpatient, if you receive any of those services listed in your booklet as needing authorization, or if you visit a provider that is not in our provider network, you will need to make sure prior authorization has been received from your HMO plan – or coverage will be denied.
Do I need a referral before seeing a specialist?
No, you do not need a referral to see an in-network specialist. However, we recommend seeing your PCP. Your PCP is best qualified to coordinate all your medical care, including visits to specialists. Services you receive from out-of-network specialists are not covered.
What if my dependents or I temporarily live out of state?
Subscribers living outside the HMO Blue service area for at least 3 months and no more than 6 months can become the "guest" of an affiliated HMO (where available), receiving benefits from the Host Plan. Dependents are also eligible for a guest membership and may renew membership after 6 months. See more information about the Away From Home Care® program.
How does my prescription drug plan work?
You have one of the prescription drug plans below. Please refer to your 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 (see the Network Directory or 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. 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.
3-Tier Drug Plan (For groups 51+ only)
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. 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 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?
Our 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 Customer Service.
Learn More About HMO Blue
Overview
Benefit Information
Away From Home Care
