Frequently Asked Questions about
HMO Blue® Plans
- How does the HMO Blue Plan work?
- Will my clients have a choice of physicians?
- Why is it important for my clients to get to know their primary care provider (PCP)?
- What if my clients are sick and their PCP is not available?
- How do my clients change their PCP?
- What happens if my client's PCP leaves the network?
- When do my clients need preauthorization?
- Do my clients need a referral before seeing a specialist?
- What if my clients or their dependents temporarily live out of state?
- How does the prescription drug plan work?
- What if I have questions about group plans?
How does the HMO Blue Plan work?
With the HMO Blue Plan, members choose a primary care provider (PCP) from our large statewide network of providers. Their PCP will be responsible for coordinating all of their health care and will be the physician who comes to know their health care needs the best. Your clients must choose a PCP when they 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 members pay for most kinds of health care services. They can check the Summary of Benefits for their copayment amounts. They do not have to meet a deductible and do not have to fill out claim forms when visiting participating providers.
Will my clients 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. Your clients can see if their physician is in our network by checking the online Provider Finder®. They 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 for my clients to get to know their primary care provider (PCP)?
Your client's PCP will become the physician who knows them best – their medical history and their present state of health. This familiarity allows their PCP to make the best decisions when they need medical care, especially during an emergency. Their PCP can also help coordinate visits to specialists.
What if my clients are sick and their PCP is not available?
HMO participating physicians have agreed to be accessible 24 hours a day for our members. Your clients can contact their PCP for advice on how to get care. If their PCP is unavailable, he or she will designate an alternate physician to provide the care or advice your clients need.
How do my clients change their PCP?
They should contact Customer Service using the toll-free number printed on the back of their member ID card.
What happens if my client's PCP leaves the network?
If your client's PCP leaves the network, they will be notified. For information about selecting a new PCP, they can contact Customer Service using the toll-free number printed on the back of their member ID card.
When do my clients need preauthorization?
HMO participating providers are familiar with the services that need preauthorization and will handle the details for your clients. However, if your clients want to coordinate their own care, they should familiarize themselves with the services listed as needing preauthorization in their Benefit Booklet. If your clients are admitted as an inpatient, if they receive any of those services listed in the booklet as needing preauthorization, or if they visit a provider that is not in our provider network, they will need to make sure preauthorization has been received from the HMO plan – or coverage will be denied.
Do my clients need a referral before seeing a specialist?
No, they do not need a referral to see an in-network specialist. However, we recommend seeing their PCP. Their PCP is best qualified to coordinate all medical care, including visits to specialists. Services members receive from out-of-network specialists are not covered.
What if my clients or their dependents 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 the prescription drug plan work?
Your clients may select one of the prescription drug plans below. BCBSNM members can refer to the Prescription Drug Plan Rider to confirm which plan they have.
Percent/Coinsurance Drug Plan
The 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, they will pay the actual percentage amount.
| Program | Percentage Members 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 – members pay 50% | N/A – members pay 50% |
The copayment will never exceed the maximum copayment listed. The 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. Members should have 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 the health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See the 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 members 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. The copayment is based on whether members 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 copayment |
The member pays this amount for a generic drug. |
| Tier 2 copayment* |
The member pays this amount for a brand-name drug that is on our drug list when no generic is available. |
| Tier 3 copayment* |
The member pays this amount for a brand-name drug that is not on our drug list or when receiving a preferred specialty drug**. |
| Tier 4 copayment for non-preferred specialty drugs** |
The member pays 15% of covered charges or up to a $250 maximum copayment per prescription for non-preferred specialty drugs. |
* If members or their doctor prefer that they receive a brand-name drug when a generic equivalent is available, they will pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
** Specialty pharmacy drugs are used to treat serious and/or chronic conditions such as multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. These medications are typically injectable and can be administered by a patient or family member. Members must use a contracting specialty network pharmacy to fill these specific prescriptions.
Under the PrimeMail Pharmacy Program, the plan may allow members to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Members should have their prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. They can 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 the health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.
See the 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. Members 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. Members pay additional costs if they receive a brand-name drug when a generic equivalent is available (even if their doctor requests the brand-name drug). Members should have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. They can 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 the 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 group plans?
For more information about our plans for groups, please contact BCBSNM Customer Service toll-free at (800) 432-0750.
Learn More About HMO Blue® for Groups:
Overview
Benefit Information
Away From Home Care®
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