2026 Medical Plan Comparison and Pharmacy Plan Information

Updated medical plan insurance information explaining the EPO options between Blue Cross Blue Shield and Presbyterian Health Plan. Also updated Express Scripts pharmacy plan information.

What Type of Health Plans Does APS Offer?

For 2026, Albuquerque Public Schools offers one type of plan - an EPO plan that includes some out-of-state, in-network access. APS employees have the option to choose between Blue Cross Blue Shield of New Mexico (BCBS) and Presbyterian Health Plan (PHP) for their medical insurance. BCBS offers in-state as well as out-of-state, in-network options. PHP offers some out-of-state coverage. Please see below for more information. There is no out-of-network coverage included with either plan. 

What is an EPO plan?

An EPO, or Exclusive Provider Organization, is a type of medical plan that offers a contracted local group of doctors, hospitals, and medical facilities for you to choose from. If you choose to get care outside of your EPO plan’s network, it usually will not be covered. The exception is for Urgent Care and emergency/ER visits, where a copay will apply. However, other charges may apply if you, or a covered dependent, are out of state and admitted to a hospital facility directly from an Urgent Care or ER visit.

What is different & what is staying the same?

Presbyterian Health Plan

• For employees and dependents living in New Mexico, the PHP EPO plan will continue to provide in-network access to contracted physicians, hospitals, and medical facilities. Only for enrolled dependents ages 17-26 who live outside of New Mexico, the Aetna network is available as an extension of the Presbyterian Health Plan EPO network. 
• The Presbyterian Health Plan will utilize the Aetna network of providers for dependents living out of state who are between the ages of 17 and 26 only. 
  
• The Aetna network is not open to employees and their dependents living in New Mexico.
• Urgent Care and Emergency/ER care are covered nationwide; a copay is required for both of these services. 

Blue Cross Blue Shield

• The BCBS EPO plan has the same network of physicians, hospitals, and medical facilities as their PPO plan. However, the EPO plan does not offer out-of-network access and will not pay out-of-network claims. 
• The BCBS EPO plan offers in and out-of-state options for in-network access. ONLY in-network claims will be paid. 
• The BCBS EPO offers the same out-of-state in-network providers as the BCBS PPO plan. 
• Urgent Care and Emergency/ER care are covered nationwide; a copay is required for these services.

Again, no out-of-network coverage is included with the BCBS EPO or PHP EPO medical plans for 2026. 

BCBS and PHP have different physicians, provider groups, and access to hospitals and medical facilities. It is important to compare the two medical plan options based on your specific needs. Comparison graphs are below. Premium rates have increased for 2026, and you can view the payroll deduction comparisons here. 

Informational videos explaining each medical plan offered will be posted on the APS Employee Wellness YouTube channel by Sept. 25, 2025. 

Comparison Grids

All cost comparisons are based on in-network physician, hospital, and medical facility access. There is no out-of-network coverage for either health plan in 2026. 

Table 1: Deductible and Coinsurance Comparison.

	Presbyterian (In-Network)	BCBS (In-Network)
Single Deductible	$500	$1,000
Two-party Deductible	$1,000	$2,000
Family Deductible	$1,250	$2,500
Coinsurance	20%	20%
Single Out-of-Pocket Maximum	$4,000	$5,000
Two-party Out-of-Pocket Maximum	$8,000	$10,000
Family Out-of-Pocket Maximum	$12,000	$12,500

EPO Medical Cost Comparison Grids

	Presbyterian (In-Network)	BCBS (In-Network)
Primary Care Visit	$20 copay	$30 copay
Specialist Visit	$50 copay	$60 copay
Virtual or Telehealth Visit	$20 copay No charge video visits through www.phs.org/videovisits	MDLIVE No Charge, Galileo $30
Preventive Care Services	Plan pays 100%	Plan pays 100%
Lab / X-Rays / Ultrasound / Other Basic Diagnostic Testing	$20 copay per day	$30 copay per day
Advanced Radiology (MRI, PET, CT scan)	$120 copay per day at a free-standing facility, or deductible and coinsurance (20%) at hospital	$120 copay per day at a free-standing facility, or deductible and coinsurance (20%) at hospital
Physical, Occupational, and Speech Therapy (refer to complete Summary of Benefits)	$20 copay per visit up to $320 annual maximum	$30 copay per visit up to $480 annual maximum
Inpatient Hospitalization	Deductible / Coinsurance  20%	Deductible / Coinsurance  20%
Urgent Care	$50 copay	$75 copay
Emergency Room	$350 copay	$450 copay
Ambulance	Subject to deductible and coinsurance 20%	Subject to deductible and coinsurance 20%
Autism Spectrum Disorder Services	No Charge	No Charge
Durable Medical Equipment, Supplies, Prosthetics (refer to complete Summary of Benefits)	20% coinsurance, the deductible does not apply	20% coinsurance, the deductible does not apply
Acupuncture, Chiropractic, Massage Therapy  (Refer to complete Summary of Benefits)	$20 copay	$30 copay
Office visit for allergy testing and treatment	$50 copay	$60 copay
Allergy extract preparation, allergy serum, and allergy injections	$10 copay	$10 copay

Table 3: Maternity Service Cost Comparison.

	Presbyterian (In-Network)	BCBS (In-Network)
Prenatal, postnatal care	$50 copay for the initial visit only, then plan pays 100%	$60 copay for the initial visit only, then plan pays 100%
Hospital Admission*	Deductible and coinsurance 20%	Deductible and coinsurance 20%

*If a newborn stays in the hospital after the mother is released, a separate deductible and 20% coinsurance applies to that extended stay for the baby.

Table 4: Diabetic Coverage Cost Comparison.

	Presbyterian (In-Network)	BCBS (In-Network)
Office visit and diabetes education	$10 copay/visit up to $260 annual max.	$10 copay/visit up to $260 annual max.
Diabetic medications	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan
Diabetic supplies, equipment, appliances,  and services	Plan pays 100%	Plan pays 100%

 

Table 5: Behavioral, Mental Health, and Substance Abuse
Service Cost Comparison.

	Presbyterian (In-Network)	BCBS (In-Network)
Outpatient Services	No Charge	No Charge
Inpatient Services	No Charge	No Charge

Express Scripts Prescription Drug Benefits

By enrolling in one of the APS medical plans, employees and dependents are automatically covered under the prescription medication program - Express Scripts. This program offers benefits through participating retail pharmacies and home delivery from Express Scripts Pharmacy and Accredo. For 2026, there are no changes to the coinsurance and maximum copay amounts for covered medications. 

EFFECTIVE JAN. 1 2026: GLP-1 Medications for Weight Loss

GLP-1s (Glucagon-Like Peptide 1 receptor agonists) are commonly used to help adults with type 2 diabetes who are struggling to reach their A1C goals. They have recently gained popularity due to their potential to promote weight loss. Starting January 1, 2026,  to support eligible APS members with weight loss, a lifestyle modification program will be offered through Teladoc Livongo. Once the eligible member has enrolled in the required lifestyle modification program for weight loss using a GLP-1 medication, a clinical prior authorization must be completed by a prescribing physician for a GLP-1 prescription to be processed and dispensed for weight loss.  GLP-1 medications for weight loss will not be available to eligible APS members unless they remain enrolled in, participating in, and meeting the lifestyle modification program requirements.  These requirements must continue to be met for GLP-1 dispensing and ongoing medication management for weight loss. View the new GLP-1 medications for weight loss requirements.

GLP-1 prescriptions (with an active prior authorization) may be dispensed for up to a 30-day supply at participating in-network retail pharmacies. Once stable on therapy, up to a 90-day supply of a maintenance dose may be dispensed through Walgreens or through Express Scripts GLP-1 dedicated home delivery pharmacy called Evernorth EnGuide ^SM Pharmacy.

Copayments/Coinsurance

Copays for generic, preferred brand, and non-preferred brand medications for 2026.

	Coinsurance	Min (retail up to 34-day supply)	Max (retail up to 34-day supply)	up to 90-day/home delivery or Walgreens
Generic (no change)	20%		$10	$20
Preferred Brand Formulary	30%	$50	$100	$150
Non-Preferred Brand	40%	$100	$175	$300

Specialty Medication Copays for 2026 (30-day supply)

Generic	Preferred Brand	Non-Preferred Brand
$100	$125	$200

Pharmacy Out-of-Pocket Maximums for 2026

Employee Only	Emp. +1	Family
$3,000	$4,000	$4,000

If you fill a prescription for a brand-name medication when a generic equivalent is available, you will pay the applicable copayment/coinsurance plus the difference in cost between the brand and the generic. The difference in cost will apply toward the out-of-pocket maximum. 

If you need long-term medication, you are allowed two fills at an in-network retail pharmacy before you must move your prescription to a 90-day supply through Express Scripts® Pharmacy or Walgreens. 

For more information about your Express Scripts benefits, go to www.express-scripts.com/APSNM. Please refer to the complete Express Scripts Summary of Benefits for more detailed information, and for information and copayment amounts specific to specialty medications. Specialty medications must be filled through Accredo, the Express Scripts specialty pharmacy. 

EPO Hospital and Physician Groups

In-network providers for BCBS (EPO)

• Lovelace Medical System & Lovelace Medical Group
• UNM Hospital & UNM Medical Group
• Optum Medical Group
• In addition, BCBS contracts with providers across the U.S., and you have out-of-state, in-network access. With the EPO plan, employees have access to the same in-network providers as they had in the PPO plan.

In-network providers for Presbyterian (EPO) 

• Presbyterian Health System & Presbyterian Medical Group
• UNM Hospital & UNM Medical Group
• Optum Medical Group in Albuquerque 
• Only for enrolled dependents ages 17-26 who live outside of New Mexico, the Aetna network is available as an extension of the Presbyterian Health Plan EPO network. The Aetna network is not open to employees and their dependents living in New Mexico.