Discover the Benefits of Dual Care Coverage

Understanding Your Dual Care Coverage

Choosing a Medicare Advantage plan from Blue Cross and Blue Shield of New Mexico is a smart move. We’ll make sure you have the right resources to help you understand your plan and learn how to get the most from it.

Is My Care Covered?

It’s easy to ask questions or voice concerns about Blue Cross Medicare Advantage Dual Care coverage. If you have questions about what the plan covers, you can:

• Read the Evidence of Coverage (EOC): This important document is in the Welcome Kit you will receive in the mail after you enroll. The EOC explains what is covered, what you pay as a member of the plan and how to file a complaint if you are not satisfied with a decision or treatment. It is also available for download on the Plan Documents page.

• Call Customer Service: After becoming a member, call the number listed on the back of your member ID card to speak with a representative who can explain your plan benefits.

Medicare Organization/Coverage Determination, Appeals and Grievances

Blue Cross Medicare Advantage Dual Care plans have processes in place to address Medicare coverage issues, complaints, and problems. If you have issues, complaints or problems with your Medicare plan or the care you receive, you have the right to file a complaint.

You can find more information on the Medical Care Appeals and Grievances page and on the Drug Coverage, Appeals and Grievances page. 

Prescription Drug Coverage

Drugs covered by Blue Cross Medicare Advantage Dual Care plans are listed in formularies (drug lists). Each plan has its own drug list that includes generic and brand name drugs. The list also provides information about drug copays and limitations, such as prior authorization, quantity limit and step therapy.

Drug lists can change, most often in the beginning of each year. Normally, any changes in the drug list are reflected in the list at the beginning of each year.

To search for medications by plan:

• Use the Drug Finder tool for the latest list of covered medications.
• Or you can download a formulary on the Forms & Documents page.

If your prescription isn’t covered, you can request an exception, coverage determination/redetermination or an appeal. Visit our Coverage Determinations and Appeals page for more information.

Learn about how drugs are placed into tiers based on cost, prior authorization, quantity limits and more. Learn about prior authorization.

If you’re new to our plan, find out how to get a limited supply of your medication that isn’t covered Learn about drug plan transition.

The Medication Therapy Management program can help you find out if the drug you take is safe, works well and fits your lifestyle at no additional cost to eligible members. Learn more about medication therapy management.

The Medicare Prescription Payment Plan can offer help with managing your out-of-pocket costs. Learn more about the Medicare Prescription Payment Plan.

Coverage Decisions

Our clinical team applies clinical guidelines to make sure you are getting safe and necessary care. There are no rewards to deny or promote care. To learn more, visit Clinical Guidelines.

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.