March 19, 2010

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Blue Cross Blue Shield of New Mexico – BlueDirect A – NEW MEXICO

A comparison of the BlueDirect A offered by Blue Cross Blue Shield of New Mexico is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application BlueDirect A Application BlueDirect A Application
Brochure BlueDirect A Brochure BlueDirect A Brochure
Copay Office Visits (nonroutine; All other services received during the office visit are subject to deductible and coinsurance as listed below): $20 copay/visit (deductible waived)
  • Office Surgery (including casts, splints, and dressings): Plan pays 90% after deductible
  • Lab Tests, X-Rays, EKGs, Other Diagnostic Tests: Plan pays 90% after deductible
  • Allergy Injections, Tests, Serum: Plan pays 90% after deductible
 Office Visits (nonroutine; All other services received during the office visit are subject to deductible and coinsurance as listed below): Plan pays 70%
  • Office Surgery (including casts, splints, and dressings): Plan pays 70%
  • Lab Tests, X-Rays, EKGs, Other Diagnostic Tests: Plan pays 70%
  • Allergy Injections, Tests, Serum: Plan pays 70%
Office Visit Office Visits (nonroutine; All other services received during the office visit are subject to deductible and coinsurance as listed below): $20 copay/visit (deductible waived)
  • Office Surgery (including casts, splints, and dressings): Plan pays 90% after deductible
  • Lab Tests, X-Rays, EKGs, Other Diagnostic Tests: Plan pays 90% after deductible
  • Allergy Injections, Tests, Serum: Plan pays 90% after deductible
 Office Visits (nonroutine; All other services received during the office visit are subject to deductible and coinsurance as listed below): Plan pays 70%
  • Office Surgery (including casts, splints, and dressings): Plan pays 70%
  • Lab Tests, X-Rays, EKGs, Other Diagnostic Tests: Plan pays 70%
  • Allergy Injections, Tests, Serum: Plan pays 70%
Deductible Individual: $500, Family: $1,500 Individual: $1,000, Family: $3,000
Coinsurance 90% after deductible 70% after deductible
Coinsurance Limit N/A N/A
Out-of-Pocket Maximum Individual: $1,000, Family: $3,000 (Includes coinsurance only) Individual: $2,000, Family: $6,000 (Includes coinsurance only)
Lifetime Maximum $5,000,000 per member $5,000,000 per member
Prescription Drugs Retail Pharmacy (up to a 30-day supply or 120 units, whichever is less):
  • Generic Drug (Tier 1): $7
  • Brand-Name Drug on Drug List (No generic equivalent available; Tier 2): $30
  • Brand-Name Drug Not on Drug List (No generic equivalent available; Tier 3): $60
  • Nonprescription Enteral Nutritional Products and Special Medical Foods (brand-name or generic; Products must be prior-approved): Plan pays 50% of covered charges (Limited to a 30-day supply during any 30-day period)
  • Specialty Pharmacy Provider (Tier 4): Plan pays 85% up to maximum copayment of $250
Mail-Order Pharmacy (lesser of a 90-day supply or 360 units; Tiers 1-3): 2 1/2 times applicable Tier 1, Tier 2, or Tier 3 copayment (specialty pharmacy drugs not available through mail-order)		 Retail Pharmacy (up to a 30-day supply or 120 units, whichever is less):
  • Generic Drug (Tier 1): $7
  • Brand-Name Drug on Drug List (No generic equivalent available; Tier 2): $30
  • Brand-Name Drug Not on Drug List (No generic equivalent available; Tier 3): $60
  • Nonprescription Enteral Nutritional Products and Special Medical Foods (brand-name or generic; Products must be prior-approved): Plan pays 50% of covered charges (Limited to a 30-day supply during any 30-day period)
  • Specialty Pharmacy Provider (Tier 4): Plan pays 85% up to maximum copayment of $250
Mail-Order Pharmacy (lesser of a 90-day supply or 360 units; Tiers 1-3): 2 1/2 times applicable Tier 1, Tier 2, or Tier 3 copayment (specialty pharmacy drugs not available through mail-order)
Emergency Room
  • Emergency Room Treatment: $100 copay/visit
  • Ambulance Services (Ground and Emergency Air Transport): Plan pays 90% after deductible
    		•
  • Emergency Room Treatment: $100 copay/visit
  • Ambulance Services (Ground and Emergency Air Transport): Plan pays 90% after deductible
    		•
    Adult Preventative Care Preventive Services:
    • Routine Adult Physicals and Gynecological Exams, Related Testing (includes routine Pap tests, mammograms, colonoscopies, cholesterol tests, urinalysis, etc.), and Immunizations: Plan pays 100% (no deductible) for first $400 in covered charges (thereafter, services are subject to deductible and coinsurance)
    		 Well-Child Care, Immunizations, Routine Testing, Routine Vision or Hearing Screenings (only through age 17): Plan pays 70%
    Child Preventative Care Well-Child Care, Immunizations, Routine Testing, Routine Vision or Hearing Screenings (only through age 17): Plan pays 100% (no deductible) for first $400 in covered charges (thereafter, services are subject to deductible and coinsurance) Well-Child Care, Immunizations, Routine Testing, Routine Vision or Hearing Screenings (only through age 17): Plan pays 70%
    Lab / X-Ray Plan pays 90% after deductible Plan pays 70%
    Maternity BlueDirect A BlueDirect A
    Physical Therapy Short-Term Rehabilitation (Occupational, Physical, and Speech Therapy; including Physical Rehabilitation and Skilled Nursing Facility):
    • Inpatient Rehabilitation (max. 30 days/year): Plan pays 90% after deductible
    • Outpatient and Office Rehabilitation (max. $3,500/year): Plan pays 90% after deductible
    		 Short-Term Rehabilitation (Occupational, Physical, and Speech Therapy; including Physical Rehabilitation and Skilled Nursing Facility):
    • Inpatient Rehabilitation (max. 30 days/year): Plan pays 70%
    • Outpatient and Office Rehabilitation (max. $3,500/year): Plan pays 70%
    Skilled Nursing Plan pays 90% after deductible Plan pays 70%
    Home Health Care Home Health Care/Home I.V. Services/Hospice (max. 100 visits/year): Plan pays 90% after deductible Home Health Care/Home I.V. Services/Hospice (max. 100 visits/year): Plan pays 70%
    Mental Health BlueDirect A BlueDirect A
    Hospital Care Inpatient Hospital/Facility Services:
    • Room and Board and Physician Care such as Physician Visits, Surgeon, and Anesthesiologist: Plan pays 90% after deductible
    • Routine Nursery Care for Covered Newborn Infants: Plan pays 90% after deductible
    • Lab, X-Ray, and Other Diagnostic Tests: Plan pays 90% after deductible
    		 Inpatient Hospital/Facility Services:
    • Room and Board and Physician Care such as Physician Visits, Surgeon, and Anesthesiologist: Plan pays 70%
    • Routine Nursery Care for Covered Newborn Infants: Plan pays 70%
    • Lab, X-Ray, and Other Diagnostic Tests: Plan pays 70%
    Optional Benefits Annual Renewable Term Life Insurance Annual Renewable Term Life Insurance