• How does the BlueDirect Plan A work?
• What is the office visit copayment for Preferred Specialists?
• Are my clients covered for the same services even if they get care from a Nonpreferred Provider?
• Is acupuncture covered?
• Is chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• What if I have questions about individual plans?
How does the BlueDirect Plan A work?
BlueDirect Plan A lets your clients see the providers they want to see. With this Preferred Provider Organization (PPO) plan your clients 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 the choice of provider will determine the amount of their out-of-pocket costs. Your clients will pay a higher deductible and higher out-of-pocket costs if they visit Nonpreferred Providers, but it is their choice to receive most health care services from any licensed provider. For most covered services, they will first meet a deductible and then will be responsible for paying coinsurance (a percentage of covered charges).
Note: BlueDirect Plan A does not cover maternity services, mental health services, or alcoholism and drug abuse treatment.
What is the office visit copayment for Preferred Specialists?
There is a $20 copay/office visit for Preferred Specialists – the same as for Preferred Primary Physicians – under Plans A and B.
Are my clients covered for the same services even if they get care from a Nonpreferred Provider?
No, some services are not covered if received from Nonpreferred Providers. The Benefit Booklet lists these services in detail. Also, benefits for some services are limited if received from Nonpreferred Providers, but are not limited if received from Preferred Providers.
Is acupuncture covered?
Yes, acupuncture procedures are covered when administered by a licensed provider and when necessary for the treatment of an illness or injury. Benefits for acupuncture, including acupuncture used as an anesthetic, are limited as specified in the Summary of Benefits and Benefit Booklet.
Is chiropractic care covered?
Chiropractic services (referred to as "spinal manipulation" in the Summary of Benefits and Benefit Booklet) are covered only when: 1) necessary for the treatment of an illness or injury, 2) administered by a licensed provider, and 3) used as short-term rehabilitation (all of these three conditions must apply). If your clients have a consultation with a licensed provider, such as to check on their progress, they will pay an office visit copayment. When therapy is performed, they will pay a deductible and coinsurance. They may be charged for an office visit, therapy, or both, depending on the nature of the visit. Benefits for spinal manipulation are limited as specified in the Summary of Benefits and Benefit Booklet.
Is outpatient surgery covered?
Yes, a variety of technical procedures for treatment or diagnosis of anatomical disease or injury are covered, such as microsurgery (use of scopes); laser procedures; treatment of fractures and dislocations; and endoscopic examinations. Benefits for surgical services also include usual and related local anesthesia, and pre- and post-operative care, including recasting. Outpatient procedures generally require prior authorization. See the Summary of Benefits and Benefit Booklet for more information.
Note: Outpatient or observation services and related physician or other professional provider services are also covered for the treatment of illness or accidental injury, depending on the type of service received or if there are special circumstances (for example, an emergency).
How does the prescription drug plan work?
The 4-Tier prescription drug plan allows BlueDirect Plan A members to get a prescription drug even if it's not on the BCBSNM Drug List and to get a brand-name drug even when a generic-equivalent is available. The copayment is based on whether they are receiving a generic drug or a brand-name drug AND whether the drug is on our Drug List.
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 | Members pay $7 when they receive a generic drug. |
| Tier 2 = middle copayment* | Members pay $30 when they receive a brand-name drug that is on our drug list. |
| Tier 3 = highest copayment* | Members pay $60 when they receive a brand-name drug that is not on our drug list and no generic is available. |
| Tier 4 = specialty drug | Members pay 15% of covered charges or up to a $250 maximum copayment per prescription. |
*If members or their doctor prefer that they receive a brand-name drug when a generic equivalent is available, they will pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
Under the PrimeMail Pharmacy Program, the plan may allow members to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Members should have their prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. They can check the printed Network Directory for participating pharmacies or search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of the health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.
See the Prescription Drug Plan Rider for details, limitations, and exclusions.
What if I have questions about individual plans?
For more information about our plans for individuals, please contact BCBSNM Customer Service toll-free at (800) 432-0750 or email us.
Learn More About BlueDirect Plan A
Overview
Benefit Information
Downloadable Forms
BlueDirect Plan A | BlueDirect Plan B | BlueDirect Plan C
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