Canfield Insurance Agency

Exclusively for the New Mexico Area

BlueChoice

Plan Options

Summary of Benefits

This is a summary only that provides you with the deductible, coinsurance, and out-of-pocket features and a very brief description of BlueChoice Plan benefits. For more complete information, see the BlueChoice Member’s Benefit Booklet.

BlueChoice Benefits – There is no lifetime maximum benefit. However, certain services have maximum annual limits. See below.		Your Share of Covered Charges
		Preferred Provider¹		Nonpreferred Provider¹
Deductible (per individual) Family deductible is three times individual amount chosen.¹		$250 $500 $1000 $2000		$500 $1000 $2000 $4000
Out-of-Pocket Limit (Includes coinsurance only - does not include deductible, copayments, penalty amounts, or noncovered charges.)²		$2000 ($5,000/family)		$4000 ($10,000/family)
Accident Treatment (100% of covered charges paid for first $500/year for services received within 90 days of accident; thereafter, services paid as any other service.)		20%		40%³
Acupuncture Treatment (max. $1500/year)⁴		20%⁴		No benefit
Ambulance Services		20%⁵
Cardiac and Pulmonary Rehabilitation		20%⁵		No benefit
Chiropractic Services (max. $1,500/year)⁴		20%⁴		No benefit
Diagnostic Services: Lab and X-Ray		20%⁵		40%⁵
Home Health Care/Home I.V. Services/Hospice (max. 100 visits/year)⁴		20%^4,5		40%^4,5
Inpatient Services (See "Short-Term Rehab" for inpatient physical therapy and skilled nursing facility services.)
Room and Board and Physician Care such as Physician Visits, Surgeon, and Anesthesiologist		20%⁶		40%⁶
Routine Nursery Care for Covered Newborn Infants		20%		40%
Office and Home Services
Physician Care or Provider Visit; Office Surgery (including casts, splints, and dressings)		20% ($20 copay per visit for a PCP office visit)		40%
Allergy Injections, Tests, Serum		20%		40%
Routine Child Care and Adult Physicals, Immunizations, Gynecological Exams		20% ($20 copay per visit for a PCP office visit)		40%
Routine Vision or Hearing Examinations (screening only through age 17)		20% ($20 copay per visit for a PCP office visit)		40%
Prescription Drugs⁷ (Member must pay difference between generic and brand-name drugs)
Retail Pharmacy Program (must pay difference between brand-name and generic): 30-day supply	$15 for a generic formulary drug $25 for a brand-name formulary drug $40 for a nonformulary drug
Mail Service Program	Same as above except two copays for a 31-90 day supply
BlueChoice Benefits		Your Share of Covered Charges
		Preferred Provider¹		Nonpreferred Provider¹
Prosthetics and Orthotics	20%⁵ (Unlimited benefit)		40%^4,5 (Maximum of $1000/year)
Short-Term Rehabilitation: Occupational, Physical, and Speech Therapy; Including Skilled Nursing Facility Inpatient Rehabilitation (max. 30 days/year)^4,6 Outpatient and Office Rehabilitation (max. $3,500/year)4		20%		No benefit
Supplies and Durable Medical Equipment		20%⁵ (Unlimited benefit)		40%^4,5 (Maximum of $1000/year)
Surgery, Inpatient or Outpatient		20%⁵		40%⁵
Therapy: Chemotherapy, Dialysis, and Radiation		20%⁵		40%⁵
TMJ Services		20%⁵		40%⁵
Transplant Services (Heart, heart-lung, liver, lung, pancreas-kidney)		20%⁵(These services are subject to a separate $5,000 out-of-pocket limit per transplant. Additional maximums are also applied to coverage.)

NOTES:

Age limit for children: Children can beare covered only through the end of the month they turn age 19. There is no extension for students.

Charges for PCP office visits: Your copayment is $20 per office visit to a Primary Care Provider (PCP) in our Preferred network of physicians. An annual deductible, plus a percentage of charges, apply to lab work, x-rays, and other covered services.

Choose who is covered: Coverage is offered just for kids, just for adults, or for the whole family.

Choose your providers: Choose from our statewide network of Preferred Provider PCPs and specialists for lowest out-of-pocket costs. Or see other providers for covered services and receive less extensive benefits.

Drug formulary: A list of drugs that have been approved by BCBSNM for use by physicians and members and are available at the lowest copayment level.

Services not covered: There are no benefits for maternity services, mental health services, or alcoholism and substance abuse treatment.

FOOTNOTES:

1 The deductible must be met before benefit payments are made.

2 After you reach the applicable out-of-pocket limit, BCBSNM pays 100 percent of your Preferred or Nonpreferred Provider covered charges, whichever is applicable.

3 Initial treatment of a medical emergency is paid at Preferred Provider level. Follow-up treatment and treatment that is not for an emergency is paid at Nonpreferred Provider level.

4 This benefit includes an annual or lifetime maximum payment or service level. See a Member’s Benefit Booklet for more information.

5 No benefit is available for certain services if prior approval is not obtained from BCBSNM. See a Member’s Benefit Booklet for a complete list of services requiring prior approval.

6 Admission review is required for inpatient admissions; you pay a $300 penalty for covered facility services if not obtained.

7 Prescription drugs must be purchased at a pharmacy that participates in the Retail Pharmacy or Mail Service Programs. (BCBSNM has contracted with a separate program for administration of your outpatient prescription drug benefits. This program is not an affiliate of BCBSNM.) Some prescription drugs require prior approval.

Deductibles and coinsurance percentages are applied to BCBSNM’s covered charges. See the BlueChoice Member’s Benefit Booklet for details.