BlueDirect Plan B FAQs
• How does BlueDirect Plan B work?
• Am I covered for the same services even if I get care from a Nonpreferred Provider?
• Is acupuncture covered?
• Is chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• If I have BlueDirect Plan B with the $5,000 deductible option, what is covered under the prescription drug plan?
• What if I have questions about benefits?
How does BlueDirect® Plan B Plan work?
BlueDirect Plan B lets you see the providers you want to see. With this Preferred Provider Organization (PPO) plan you do not have to choose a Primary Care Provider (PCP) and you do not need a referral to see a specialist. Providers are classified as "Preferred" (in-network) or "Nonpreferred" (out-of-network), and your choice of provider will determine the amount of your out-of-pocket costs. You will pay a higher deductible and higher out-of-pocket costs if you visit Nonpreferred Providers, but it is your choice to receive most health care services from any licensed provider. For most covered services, you will first meet a deductible and then you will be responsible for paying coinsurance (a percentage of covered charges).
Note: BlueDirect Plan B does not cover maternity services, mental health services, or alcoholism and drug abuse treatment.
Am I covered for the same services even if I get care from a Nonpreferred Provider?
No, some services are not covered if you receive them from Nonpreferred Providers. The Benefit Booklet will list these services in detail. Also, benefits for some services are limited if you receive them 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 are covered the same as services from any other licensed provider, and benefits are limited as specified in the Summary of Benefits, based on the type of service such as spinal manipulation, physical therapy, etc. Some services such as office visits and x-rays are not limited. If you have a consultation with a licensed provider, such as to check on your progress, you will pay an office visit copayment. When therapy is performed, you will pay deductible and coinsurance. You may be charged for an office visit, therapy, or both, depending on the nature of the visit.
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?
BlueDirect Plan B options feature a 4-Tier prescription drug benefit, except for the $5,000 deductible option (which covers mandated drugs only, such as insulin, diabetic supplies, and special medical foods).
The 4-Tier prescription drug plan allows you 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. Your copayment is based on whether you 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 | You pay $10 when you receive a generic drug. |
| Tier 2 = middle copayment* | You pay $35 when you receive a brand-name drug that is on our drug list. |
| Tier 3 = highest copayment* | You pay $75 when you receive a brand-name drug that is not on our drug list and no generic is available. |
| Tier 4 = specialty drug | You pay 15% of covered charges or up to a $250 maximum copayment per prescription. |
*If you or your doctor prefer that you receive a brand-name drug when a generic equivalent is available, you'll pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
Under the PrimeMail Pharmacy Program, your plan may allow you to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. Search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of your 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, exclusions, and Specialty Pharmacy Program information.
If I have BlueDirect Plan B with the $5,000 deductible option, what is covered under the prescription drug plan?
This plan only covers the following mandated drugs when dispensed by a participating pharmacy or ordered through the PrimeMail mail-order service:
- prescription drugs for controlling blood sugar levels
- insulin and glucagons emergency kits
- insulin needs, syringes, and diabetic supplies
- special medical foods to treat and compensate for metabolic abnormality to maintain adequate nutritional status (these nonprescription products are subject to 50% coinsurance and must be prior-approved by BCBSNM)
Prescription drug payments are as follows:
| Type of Prescription | Percentage of Covered Charge | Minimum Percentage Amount | Maximum Percentage Amount |
| Generic Diabetic Drugs and Supplies | 25% | $20 | $75 |
| Brand-name Diabetic Drugs and Supplies | 50% | $40 | $125 |
| Special Medical Foods (limited to a 30-day supply during any 30-day period; requires approval) | 50% of covered charges | ||
For each percentage amount listed above you can obtain up to a 30-day supply or 180 units (e.g., pills), whichever is less, of a single drug or other item covered by the rider. If more than 180 units are needed to reach a 30-day supply, prior approval is required.
Prescriptions must be purchased at a participating pharmacy unless required as the result of an emergency, as defined in the Prescription Drug Plan Rider. See the Prescription Drug Plan Rider for details, limitations, and exclusions.
What if I have questions about benefits?
If you are applying for BlueDirect and have benefit questions, please call 1-866-445-1396.
If you are a BlueDirect member and have questions, call BCBSNM Customer Service at the toll-free number on the back of your BCBSNM member ID card.
