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Blue Cross Blue Shield
New Mexico |
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Comparison Chart: All Plans
Summary of BlueDirect Medical Benefits
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MEMBER'S SHARE OF COVERED CHARGES |
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Blue Direct Plan A1 |
Blue Direct Plan B1 |
Blue Direct Plan C1
This plan does not cover services received from N onpreferred Providers, except in an emergency |
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Preferred Provider |
Nonpreferred Provider |
Preferred Provider |
Nonpreferred Provider |
Preferred Provider |
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Highlights of Member Costs |
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Life time Maximum Benefit (Some services have annual or lifetime limits.) |
$ 5,000,000 |
$5,000,000 |
$5,000,000 |
$5,000,000 |
$5,000,000 |
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Calendar Year Deductible Options (Family deductible is three times individual amount chosen.) |
$100 $250 $500 $1,000 |
$200 $500 $1,000 $2,000 |
$250 $500 $1,000 $2,000 $5,000 |
$500 $1,000 $2,000 $4,000 $10,000 |
$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.) |
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Annual Out-of-Pocket Limit (Does not include deductible, pena lty amounts, and noncovered cha rges; copa yments for Plans A and B a re not included. Family limit is three times individual amount chosen.) |
$1,000 |
$2,000 |
$2,000 |
$4,000 |
$5,000 |
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Highlights of Benefits |
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Office Visits (for nonroutine; other services received during an office visit are subject to deductible and coinsurance as listed.) |
$20 copay/visit |
30% |
$20 copay/visit |
40% |
Preferred Primary Provider (PPP)2· $ 40 copay/ visit Specia list2· $ 55 copay/ visit |
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Office Surgery (including casts, splints, & dressings)3 |
10% |
30% |
20% |
40% |
PPP-$40 copay/ visit; Specialist -$ 55 copay/visit |
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Lab Tests, X-Rays, EKGs, and other Diagnostic Tests3 |
10% |
30% |
20% |
40% |
30% (no deductible) |
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Allergy Services (injections, tests, serum) |
10% |
30% |
20% |
40% |
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 care a nd immunizations; vision/ hearing screenings through age 17) |
Pays 100% (no deductible) for first $ 400 in covered charges, including related testing. There-after, subject to deductible and coinsurance. |
30% |
Pays 100% (no deductible) for first $400 in covered charges, including related testing. Thereafter, subject to deductible and coinsurance. |
40% |
Exam: PPP · $40 copay/ visit; Specia list · $ 5 5 copay/visit Rela ted Testing: Deductible/ Coinsura nce |
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Emergency Services |
$100 copay/visit |
$100 copay/visit |
$150 copay/visit |
$150 copay/visit |
$300 copay/visit |
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Urgent Care Facility |
$30 copay/visit |
30% |
$30 copay/visit |
40% |
$100 copay/visit |
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Hospital · Inpatient and Outpatient 3,4 |
10% |
30% |
20% |
40% |
30% |
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Surgery · Inpatient and Outpatient 3,4 |
10% |
30% |
20% |
40% |
30% |
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Organ Transplants 5 |
10%3,4 |
No benefit |
20%3,4 |
No benefit |
Usual copays or coinsurance based on place of treatment and type of service3,4 |
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Other Covered Services6 |
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Out-of-Area Care · Therapy: Chemotherapy, Dialysis, and Radiation · Prosthetics and Orthotics · Acupuncture Services ($1,500/calendar year max.) · Lab Tests, X-Rays, and Other Diagnostic Tests · Ambulance Services · Spinal Manipulation ($1,500/calendar year max.) · Prescription Drug Benefits (see following page) · Home Health Care/ Home I.V. Services/Hospice (100 visits/calendar year max.) · Supplies and Durable Medical Equipment · TMJ Services and Denta l/Facial Accidents · 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 maternity 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 tothe Plan Benefit Booklets and Prescription Drug Plan Ridersfor more complete benefit information. |
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