BlueDirect Plan C FAQs
• How does BlueDirect Plan C work?
• What is a PPO Primary Provider (PPP)?
• The Summary of Benefits lists "Specialty Physician Office Services." What is a specialist?
• Why are there separate charges when visiting a provider?
• What are my out-of-pocket costs in an emergency room?
• Is acupuncture covered?
• Is chiropractic care covered?
• Is outpatient surgery covered?
• How does the prescription drug plan work?
• If I have BlueDirect Plan C 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 C work?
As a BlueDirect Plan C member, you must use Preferred Providers (in-network providers) to receive covered benefits and cost savings of the plan. You do not have to choose a Primary Care Provider (PCP) and you do not need a referral to see a specialist. There is no coverage for services received from Nonpreferred Providers (out-of-network providers), except in an emergency.
Note: BlueDirect Plan C does not cover maternity services, mental health services, or alcoholism and drug abuse treatment.
What is a PPO Primary Provider (PPP)?
A PPO Primary Provider (PPP) is a Preferred Provider in one of the following medical specialties: Family Practice, General Practice, Internal Medicine, Obstetrics/Gynecology, Gynecology, or Pediatrics. PPPs do not include physicians specializing in any other fields such as Obstetrics only, Geriatrics, Pediatric Surgery, or Pediatric Allergy. When you see a PPP for an office visit, you pay a copayment. To find a PPP, search our Provider Finder®. Members may also call Customer Service at the number on the back of their BCBSNM member ID card for help finding a PPP.
The Summary of Benefits lists "Specialty Physician Office Services." What is a specialist?
A specialist is a health care professional whose practice is limited to a certain branch of medicine such as specific procedures, specific body systems, or certain types of diseases. A PPO specialist has a Preferred Provider contract with his/her BCBS Plan and is not a "PPP" as defined above. A PPO specialist does not include hospitals or other treatment facilities, pharmacies, equipment suppliers, ambulance companies, or similar ancillary health care service providers.
Why are there separate charges when visiting a provider?
Members always pay an office visit copayment. There may be separate charges for any therapies or diagnostic tests performed during or as a result of a visit, these charges are based on type of service and place of service (e.g., surgery performed in a provider's office or X-rays at an outpatient facility). You may be responsible for paying additional coinsurance and deductible for these services. Please check the Benefit Booklet for more information.
What are my out-of-pocket costs in an emergency room?
The Emergency Room copayment covers both facility and provider charges. See the Benefit Booklet for more information about covered emergency services.
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 your 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 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. 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?
BlueDirect Plan C options feature a 25/50 percent prescription drug benefit, except for the $5,000 deductible option (which covers mandated drugs only, such as diabetic insulin and supplies).
Your copayment for prescription drugs purchased through this drug plan is 25 percent of the covered charge for generic drugs and 50 percent of the covered charge for brand-name drugs. If the percentage of the covered charge falls between the minimum/maximum copayment, you will pay the actual percentage amount.
| Program | Percentage You Pay | Minimum Amount | Maximum Amount |
| Retail Pharmacy: Up to a 30-day supply or 180 units, whichever is less. | |||
| Generic drug | 25% | $20 | $75 |
| Brand-name drug | 50% | $40 | $125 |
| PrimeMail Pharmacy Mail-Order Service: Up to a 90-day supply or 540 units, whichever is less. | |||
| Generic drug | 25% | $40 | $150 |
| Brand-name drug | 50% | $80 | $250 |
| Prior-approved enteral nutritional products and special medical foods. | 50% | N/A – you pay 50% | N/A – you pay 50% |
Your copayment will never exceed the maximum copayment listed. In all cases, your copayments are applied to an annual out-of-pocket limit of $2,500. (This limit is separate from the medical plan's out-of-pocket limit.) Be sure to have your prescriptions filled at a participating pharmacy (search the Provider Finder®) or through the PrimeMail Pharmacy mail-order service. Coverage is always subject to the limitations of your health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See your Prescription Drug Plan Rider for details, limitations, and exclusions.
The BCBSNM Drug List does not apply with the 25/50 Percent Prescription Drug Plan.
If I have BlueDirect Plan C with the $5,000 deductible option, what is covered under the 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.
