• How does the PPO Plan work?
• Am I covered for the same services even if I get care from a Nonpreferred Provider?
• How does my prescription drug plan work?
• Do I have dental coverage?
• Do I have vision coverage?
• What if I have questions about my medical plan benefits?
This Preferred Provider Organization (PPO) plan lets you see the providers you want to see. You do not have to choose a primary care provider (PCP) 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. If you visit Preferred Providers, you do not pay a deductible for most services. Also, for most services from Preferred Providers, you will pay a predictable copayment. For most services from a Nonpreferred Provider, you will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges). Some services are only covered if you receive them from a Preferred Provider. It is your choice to receive most covered health care services from any licensed provider.
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. 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.
How does my prescription drug plan work?
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).
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. For Specialty Pharmacy drugs, you pay a 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 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 pharmacy in New Mexico (under More Searches select Find a Pharmacy, then choose Other BCBSNM Prescription Drug Plans - Prime Therapeutics Network). 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 Prescription Drugs to access the BCBSNM Drug List; learn about the Specialty Pharmacy Program and the PrimeMail Prescription Mail-Order Program; and view Rx prior authorization criteria, downloadable forms, and more.
If you selected a dental plan when you enrolled, you have dental benefits. Blue Cross and Blue Shield of New Mexico (BCBSNM) does not administer your dental benefits – these are administered by Delta Dental or United Concordia (depending on the plan you selected during enrollment). For questions about your dental plan or to check your enrollment status, call your dental carrier or visit their Web site:
• Delta Dental – 505-855-7111 or 1-877-395-9420, www.deltadentalnm.com**
• United Concordia – 1-800-332-0366, www.ucci.com**
If you selected the vision plan when you enrolled, you have vision benefits. BCBSNM does not administer your vision benefits – these are administered by Davis Vision. For questions about your vision plan or to check your enrollment status, call or visit their Web site:
• Davis Vision – 1-800-999-5431, www.davisvision.com**
What if I have questions about my medical plan 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). If you call after hours, you can leave a message and we will return your call by the next business day. We also have Spanish-speaking representatives to assist members. 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 e-mail questions to BCBSNM Customer Service.
Learn More About Your PPO Plan
Overview
Benefit Information
**We do our best to ensure that the information on the other health-related Web sites listed above is useful, but can't be responsible for the content of those sites or any information you may take from them (please read our legal disclaimer). When you click on a choice above, it will open in a new window so that you can explore that site without having to leave here. When you are through visiting the other site, you can close that window and return to the BCBSNM site.
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