Albuquerque Public Schools
2025 Medical Plan Comparison Information
Updated medical insurance information explaining the EPO options between Blue Cross Blue Shield and Presbyterian Health Plan. Cigna Healthcare will no longer be offered in 2025.
What Type of Health Plans Does APS Offer?
Effective January 1, 2025, Albuquerque Public Schools will offer one type of plan - an EPO plan that will include 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. Both will offer in-state as well as out-of-state, in-network options. 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 who live in New Mexico, the PHP EPO plan will continue to provide in-network access to contracted physicians, hospitals, and medical facilities. The only change is the addition of the Aetna network for out-of-state dependents ages 17-26.
- The Presbyterian Health Plan will utilize the Aetna network of providers for dependents living out-of-state who are ages 17-26 only.
- The Aetna network is not open to employees and their dependents living in New Mexico.
- Urgent Care and Emergency/ER care is covered nationwide; a copay is required for these services.
Blue Cross Blue Shield
- The BCBS EPO plan has the same network of physicians, hospitals, and medical facilities as the current 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 out-of-state, in-network access - only.
- The BCBS EPO offers the same out-of-state in-network providers as your current BCBS PPO plan.
- Urgent Care and Emergency/ER care is 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 2025.
BCBS and PHP have different physicians, provider groups, and hospital and medical facility access. It is important to compare the two medical plan options based on your specific needs. Comparison graphs are below. Premium rates have increased for 2025 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. 27, 2024.
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 2025.
| 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 Copay | $20 | $30 |
| Specialist Copay | $50 | $60 |
| Virtual or Telehealth Visit | $20 |
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 | $75 |
| 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 | $30 |
| Office visit for allergy testing and treatment | $50 | $60 |
| Allergy extract preparation, allergy serum, and allergy injections | $10 | $10 |
| 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.
| 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% |
| 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 2025, there are copay increases for preferred brands, non-preferred brands, and specialty drug as well as an increase to the out-of-pocket maximum.
Copayments/Coinsurance
Copays for Preferred Brand Formulary and Non-Preferred Brand for 2025
| Coinsurance |
Min (retail up to 34-day supply) |
Max (retail up to 34-day supply) | 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 2025
| Generic | Preferred Brand | Non-Preferred Brand |
| $100 | $125 | $200 |
Pharmacy Out-of-Pocket Maximums for 2025
| 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 express-scripts.com/aps.nm. 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
- Optum Medical Group in Albuquerque
- Presbyterian Aetna EPO in-network access to physicians, hospitals, and medical facilities for out-of-state dependents ages 17-26.