Frequently Asked Questions
about the PPO Plan
Your SONM health plan options let 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). You'll generally pay more if you receive services from Nonpreferred Providers, but it is your choice to receive most covered health care services from any licensed provider. For most services, you will have a deductible to meet and then be responsible for paying a copay or coinsurance (a percentage of covered charges). Transplants and certain other services listed on your Summary of Benefits are covered only if you receive them from a Preferred Provider.
You will use the Blue Cross and Blue Shield PPO provider network to access contracted doctors, hospitals, and other health care professionals.
A Primary Preferred 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 set copayment rather than a percentage of the charges (the deductible is waived). To find a PPP in New Mexico, search our online Provider Finder®. You may also call Customer Service at the number on the back of your member ID card (877-994-2583) for help looking for a PPP. Your health plan does not require you to visit a PPP or get a referral from a PPP to see a specialist.
A Nonpreferred Provider (out-of-network provider) has not contracted with BCBSNM or another Blue Cross and Blue Shield (BCBS) company, either directly or indirectly, to be part of the preferred or PPO provider network.
You have out-of-network benefits for most services, but you will pay a higher deductible and coinsurance if you seek care from a Nonpreferred Provider. Please refer to your Summary of Benefits or Benefit Booklet for applicable deductibles and coinsurance, and to see a detailed list of these services. Also, benefits for some services are limited if you receive them from Nonpreferred Providers, but are not limited if received from Preferred Providers.
To locate a provider, search our Provider Finder®.
Yes, with the BlueCard® Program you have help accessing doctors and hospitals contracted as providers with Blue Cross and Blue Shield companies across the country. If you are traveling in the U.S. and need to find a provider when out of the area that BCBSNM serves, contact the local Blue Cross and/or Blue Shield company, call the BlueCard Access toll-free at 800-810-BLUE (2583), or search the Blue National Doctor and Hospital Finder. If you are outside the U.S. and need emergency medical care, go to the nearest hospital; call the BlueCard Worldwide® Service Center at 800-810-BLUE (2583) or call collect at 804-673-1177 if you're admitted. Always carry your BCBSNM member ID card, as it contains important information your provider will need to file claims correctly.
Certain services require approval from BCBSNM. If approval is not obtained, BCBSNM will not pay for them. This approval is called “preauthorization.” The list of services that require preauthorization is in the Benefit Booklet. To request preauthorization, you or your provider must call BCBSNM Health Services. Call 505-291-3585 in Albuquerque, or toll-free at 800-325-8334, Monday through Friday, from 8 a.m. to 5 p.m. Mountain Time.
Note: Your plan includes behavioral health and chemical dependency services. Preauthorization is required for inpatient, residential treatment, partial hospitalization and some outpatient services. Request preauthorization from the BCBSNM behavioral health services administrator. Call toll-free at 888-898-0700. Phones are open 7 days a week, 24 hours a day.
You can log in to Blue Access for Members and request a new member ID card, or call Customer Service at 877-994-2583. It will take up to two weeks to receive a new card. If you need a new card immediately, you can print a temporary ID card to use until your permanent card arrives.
No, the deductibles are waived when you receive preventive services from Preferred Providers. Preventive services for adults, such as routine physicals and related routine testing, including mammograms, cholesterol tests, and immunizations are covered at 100 percent. Preventive services for children, including well-child care, routine vision or hearing screenings, and routine testing and immunizations are covered at 100 percent. If you receive preventive services from Nonpreferred Providers, you will pay 30 percent.
Blue Cross and Blue Shield of New Mexico (BCBSNM) does not administer your prescription drug plan – it is administered by Express Scripts®. For questions about your pharmacy benefits, call Express Scripts customer service toll-free at 800-743-1720 or visit www.express-scripts.com.*
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 SONM Designated Service Unit toll-free at 877-994-2583; the number is printed on the back of your member ID card. Please have your ID card available when you call. You can also contact Customer Service with a secure message through Blue Access for Members.