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Blue Cross Blue Shield
New Mexico |
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• BlueDirect® Plan C Benefit Information
BlueDirect® Plan C offers the benefits that your clients need most. Special features of this plan include:
- preventive care
- wide range of covered services, including emergency and urgent care, specialist services, hospitalization, surgery, acupuncture, chiropractic, prescription drug benefits, diagnostic tests, and organ transplants
- 24/7 Nurseline
- coverage when traveling, including the unique BlueCard® program
Summary of BlueDirect
Medical Benefits |
MEMBER'S SHARE OF COVERED CHARGES |
Blue Direct Plan C1
This plan does not cover services received from Nonpreferred
Providers, except in an emergency |
|
Preferred Provider |
|
High lights of Member Costs |
Life time Maximum Benefit
(Some services have annual or lifetime limits.) |
$5,000,000 |
Calendar Year Deductible Options
(Family deductible is three times individual amount chosen. ) |
$500 $1,000 $2,000 $5,000
(Only covered charges for services subject to a percentage "coinsurance"
are subject to the deductible, except for outpatient diagnostic tests.) |
Annual Out-of -Pocket Limit
Does not include deductible, penalty a mounts, and noncovered charges; copayments for Plans A and B are not included. Family limit is three times individual amount chosen. |
$5,000 |
|
Highlights of Benefits |
Office Visits
for nonroutine; other services received during an office visit are subject to deductible and coinsurance as listed. |
Preferred Primary Provider (PPP) 2- $40 copay/visit Specialist 2- $55 copay/visit |
Office Surgery
(including casts, splints, and dressings)3 |
PPP -$40 copay/visit; Specialist -$55 copay/visit |
Lab Tests, X-Rays, EKG s,
and other Diagnostic Tests3 |
30% (no deductible) |
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Allergy Services (injections, tests, serum) |
Allergy Services: PPP -- $40 copay/visit; Specialist -- $55 copay/visit Allergy Serum: 50% |
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Preventive Care (Routine adult exams and screenings; well-child ca re and immunizations; vision/ hearing screenings through age 17 ) |
Exam: PPP - $40 copay/visit; Specialist - $55 copay/visit Related Testing: Deductible/Coinsurance |
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Emergency Services |
$300 copay/visit |
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Urgent Care Facility |
$100 copay/visit |
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Hospital - Inpatient and Outpatient 3,4 |
30% |
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Surgery - Inpatient and Outpatient 3,4 |
30% |
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Organ Transplants 5 |
Usual copays or coinsurance based on place of treatment and type of service 3,4 |
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Other Covered Services6 |
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· Out-of-Area Care ·Acupuncture Services ($ 1,500 / calendar year max.) · Spinal Manipulation ($ 1,500 / calendar year max.) · Supplies and Durable Medical Equipment · Therapy: C hemotherapy, Dialysis, and Radiation · Lab Tests, X-Rays, and Other Diagnostic Tests · Prescription Drug Benefits (see following page) · TMJ Services and Dental/Facial Accidents · Prosthetics and Orthotics · Ambulance Services · Home Health Care/ Home I.V. Services/Hospice (100 visits/ calendar year max.) · Short-Term Rehabilitation (Occupational, Physical, and Speech Therapy; 30 days inpatient and $3500 outpatient/calendar year max.) |
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Important note: BlueDirect does not provide benefits for ma ternity care (including any pregnancy-related condition), behavioral health conditions, or chemical dependency (alcoholism or drug abuse). |
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This is only a brief description of benefits. Some services require Admission Review and/or Prior Approval. Some services have annual or lifetime limits. Please refer to the Plan Benefit Booklets and Prescription Drug Plan R iders for more complete benefit information. |
A Division of Health Care Services Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association |
View and print benefit information:
 Or call Toll Free: 1-800-831-3270 , contact or email us!
Or download our Individual Health Insurance Application  in Acrobat PDF format.
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USA-HealthInsurance® offers affordable medical coverage from Blue Cross Blue Shield and other nationwide insurance companies to provide you with your health insurance needs.
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