Albuquerque Public Schools
Medical Plan Comparison Information
Tables comparing the APS medical insurance plans and an explanation of the two types of medical plan options available.
Which Health Plans does APS Offer?
Albuquerque Public Schools offers two types of health insurance plans: EPO and PPO. The tables below compare EPO In-Network, PPO In-Network, and PPO Out-of-Network costs. Please read the information carefully and choose the plan that best fits you and your family's needs.
Note: If you have out-of-state dependents it is important to choose the right health plan for your family. Read more detail on the differences between EPO and PPO plans as well as what hospital and medical providers are generally contracted with each plan.
What is an EPO?
- An EPO, or Exclusive Provider Organization, is a type of health plan that offers a local network of doctors and hospitals for you to choose from, with few to no out-of-state options.
- If you choose to get care outside of your EPO plan’s network, it usually will not be covered (except in an emergency/ER circumstance), less the copay.
When to Consider an EPO
- If you’re looking for slightly lower copays with higher monthly premiums.
- Deductibles and out-of-pocket maximums are slightly lower.
- Your and your family (if applicable) are willing to receive healthcare services from contracted Presbyterian Health Plan providers and facilities.
What is a PPO?
- A PPO, or Preferred Provider Organization, is a type of health plan that offers a nationwide network of doctors and hospitals, for more choice.
- PPOs have different costs for in-network services and out-of-network services. An out-of-network provider and services will be more expensive.
When to Consider a PPO
- If you're willing to pay slightly higher copays but lower monthly premiums to get more choice and flexibility in choosing your physician and health care options.
- Deductibles and out-of-pocket maximums are slightly higher.
- You have dependents living out of state or you want the flexibility of receiving care outside of New Mexico.
Note: If you have out-of-state dependants – it is important to choose the right health plan.
EPO and PPO Medical Cost Comparison Grids
Table 1: Copay and Deductible Cost Comparison
EPO option is Presbyterian Health Plan. PPO options are Cigna and BlueCross BlueShield (BCBS).
| Presbyterian (In-Network) |
BCBS/Cigna (In-Network) | BCBS/Cigna (Out-of-Network) | |
|---|---|---|---|
| Primary Care Copay | $20 | $30 | Deductible / Coinsurance |
| Specialist Copay | $50 | $60 | Deductible / Coinsurance |
| Video Visit | No Charge | No Charge | Not Covered |
| Preventive Care Services | Plan pays 100% | Plan pays 100% | Deductible / Coinsurance |
| Lab / X-Rays / Ultrasound / Other Basic Diagnostic Testing | $20 copay per day | $30 copay per day | Deductible / Coinsurance |
| Advanced Radiology (MRI, PET, CT scan) |
$120 copay per day at a free-standing facility, or deductible and coinsurance at hospital |
|
Deductible / Coinsurance |
| 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 |
Deductible / Coinsurance |
| Inpatient Hospitalization | Deductible / Coinsurance |
Deductible / Coinsurance |
Deductible / Coinsurance |
| Urgent Care | $50 | $75 | $75 |
| Emergency Room | $350 copay | $450 copay | $450 copay |
| Ambulance | Subject to deductible and coinsurance | Subject to in-network deductible and coinsurance |
Subject to in-network deductible and coinsurance |
| Autism Spectrum Disorder Services | No Charge | No Charge | Deductible / Coinsurance |
| 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 |
Deductible / Coinsurance |
| Acupuncture, Chiropractic, Massage Therapy (Refer to complete Summary of Benefits) | $20 | $30 | Deductible / Coinsurance |
| Office visit for allergy testing and treatment | $50 | $60 | Deductible / Coinsurance |
| Allergy extract preparation, allergy serum, and allergy injections | $10 | $10 | Deductible / Coinsurance |
| Presbyterian (In-Network) | BCBS/Cigna (In-Network) | BCBS/Cigna (Out-of-Network) | |
|---|---|---|---|
| Single Deductible | $500 | $1,000 | $5,000 |
| Two-party Deductible | $1,000 | $2,000 | $10,000 |
| Family Deductible | $1,250 | $2,500 | $15,000 |
| Coinsurance | 20% | 20% | 50% |
| Single Out of Pocket Maximum | $4,000 | $5,000 | $8,500 |
| Two-party Out of Pocket Maximum | $8,000 | $10,000 | $14,875 |
| Family Out of Pocket Maximum | $12,000 | $12,500 | $21,250 |
| Presbyterian (In-Network) |
BCBS/Cigna (In-Network) | BCBS/Cigna (Out-of-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% |
Deductible and coinsurance |
| Hospital Admission |
Deductible and coinsurance |
Deductible and coinsurance |
Deductible and coinsurance |
| Presbyterian (In-Network) | BCBS/Cigna (In-Network) | BCBS/Cigna (Out-of-Network) | |
|---|---|---|---|
| Office visit and diabetes education |
$10 copay/visit up to $260 annual max. |
$10 copay/visit up to $260 annual max. |
Deductible and coinsurance |
| Diabetic medications | Refer to Prescription Drug Plan |
Refer to Prescription Drug Plan |
Refer to Prescription Drug Plan |
| Diabetic supplies, equipment, appliances, and services |
Plan pays 100% | Plan pays 100% | Deductible and coinsurance |
| Presbyterian (In-Network) | BCBS/CIGNA (In-Network) | BCBS/Cigna (Out-of-Network) | |
|---|---|---|---|
| Outpatient Services | No Charge | No Charge | Deductible and coinsurance |
| Inpatient Services | No Charge | No Charge | Deductible and coinsurance |
About Senate Bill 317
Senate Bill 317 as passed by the New Mexico Legislature in 2021 provides that, as of January 1, 2022, the APS medical plans shall not impose patient cost-sharing on behavioral health services. This means that in-network services and prescription medications for treatment, rehabilitation, prevention, and identification of mental illnesses, substance abuse disorders, and trauma spectrum disorders are not subject to copayments, deductibles, and/or coinsurance. Under SB317, the APS plan is required to cover these in-network services at 100% paid by the plan (no charge to the patient).
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.
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. Starting January 1, 2023, the out-of-pocket maximum for an employee only is $2,500 and $3,500 for employee +1 or employee + family coverage.
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 ExpressScripts® Pharmacy or Walgreens.
For more information about your Express Scripts benefits go to express-scripts.com/aps.nm
Presbyterian/BCBS/Cigna Provider Access Breakdown
In-network providers for BCBS (PPO)
- 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-network access
In-network providers for Presbyterian (EPO) and Cigna (PPO)
- Presbyterian Health System & Presbyterian Medical Group
- Optum Medical Group in Albuquerque
- Cigna - UNM Hospital/UNM Children’s Hospital
- In addition, Cigna contracts with providers across the U.S. and you have out-of-network access