Frequently Asked Questions About Your Plans

As a Standard Option member, you will receive medical care from University of New Mexico Hospital (UNMH) providers and facilities. The network also includes additional independently contracted providers including, but not limited to, pharmacies, urgent care centers, laboratories, home health care providers, and durable medical equipment suppliers. You do not need to sign up with a PCP or notify us if you change PCPs. However, we recommend that you select a PCP as a personal physician who can come to know you and your health care needs.
With the Standard Option you pay predictable copayments for health care services from in-network providers. Check your Summary of Benefits for additional copayment amounts. You do not have to meet a deductible and do not have to fill out claim forms when visiting participating providers in the Standard (LoboCare) Network.

For in-network services, Standard Option members must receive services from providers in the Standard Network. These providers include University of New Mexico Hospital providers and facilities as well as additional independently contracted providers including, but not limited to, pharmacies, urgent care centers, laboratories, home health care providers, and durable medical equipment suppliers. Members also have coverage for services from out-of-network providers.

Yes, members with the Standard Option Plan have out-of-network coverage. Under the Standard Option, an out-of-network provider is a provider that is not listed as a Standard Network provider. If you receive services from an out-of-network provider, you must first meet a deductible and then pay a percentage of the covered charges. Members may also have to file claim forms and may be responsible for charges over the allowable fee. Please review your Summary of Benefits and Benefit Booklet thoroughly as some services, such as routine physicals, are not covered out-of-network.

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.

UNMH providers and facilities and the BCBSNM network include many providers with extended hours. When you visit your PCP, you may want to ask about his/her after-hours policies; many physicians work in groups and have a doctor on-call for after-hours coverage. If you have an urgent condition, you may also visit one of the urgent care centers in the BCBSNM network.

Subscribers living outside the BCBSNM 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.

The 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 for prescription drugs is based on whether the drug you receive is a generic or a brand-name drug AND whether the drug is on the BCBSNM Drug List.

 

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 times the retail copayment.

Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program. 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 Benefit Booklet for details, limitations, and exclusions.

View the BCBSNM Drug List.

If you have any questions about your prescription drug benefits, call Customer Service at the toll-free number on the back of your BCBSNM member ID card.

Our 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 can also contact Customer Service with a secure message through Blue Access for Members^SM.