Core Care Bronze 5 LCS

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Benefits and Coverage (assuming you use preferred providers) (Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)
Plan id	19722NM0010006-03
CSR Variation Type	Limited Cost Sharing Plan Variation
Insurance Company	Molina Healthcare
Plan Type	HMO
Plan Metal Level	Bronze
Link to Plan's Doctor Directory	View Plan's Doctor Directory
List of Hospitals in Plan's Network	Show Hospitals
Summary of Benefits and Coverage	View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC)
Monthly Premium Cost after Subtracting the Estimated Subsidy (Subsidies are not available for Catastrophic Plans)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low (for Very Healthy Consumers "Low" is Defined as Only Preventive Care)	Use 2021 New Mexico Plan Comparison Tool to find out.
Your Chances of Having a Good Year--a Year with No More Than Low-Usage
Cost in an Average Year: Average for People Like You
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year
Your Chances of Having a Bad Year--a Year with Very High Usage
Actual Maximum Out-of-Pocket (includes premiums)
In-Network Deductible (Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)	$0
Extra Deductible for Drugs	$3,000
Doctor Visits
Doctor Visit - Preventive Care	No Charge
Doctor Visit - Primary Care	$60 Copay
Doctor Visit - Specialist	$150 Copay
Doctor Visit - Well Baby Visits and Care	No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant)	$60 Copay
Hospital
Inpatient Hospital Facility	$1500 Copay per Day
Inpatient Hospital Physician/Surgeon	$150 Copay
Outpatient Hospital Facility	$130 Copay
Outpatient Hospital Physician/Surgeon	$100 Copay
Inpatient Maternity Services	$150 Copay
Emergency
Emergency Room Services	$1,850 Copay
Emergency Medical Transportation	$130 Copay
Urgent Care Centers or Facilities	$60 Copay
Drugs
Plan's Drug Formulary	View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy	$27 Copay
Preferred Brand Drug on Formulary in a Local Pharmacy	$130 Copay
Non-Preferred Brand Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work)	$60 Copay
X-Rays	$140 Copay
Imaging (CT/PET Scans, MRI, etc)	$1,000 Copay
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services	$1500 Copay per Day
Mental/Behavioral Health Outpatient Services	$60 Copay
Substance Use Disorder Inpatient	$1500 Copay per Day
Substance Use Disorder Outpatient	$60 Copay
Vision/Hearing Aids
Routine Eye Exam for Child	No Charge
Eye Glasses for Child	No Charge
Routine Eye Exam - Adult
Hearing Aids	$130 Copay
Child Dental Coverage
Dental Check-Up for Children
Basic Dental Care – Child
Major Dental Care – Child
Orthodontia – Child
Adult Dental Coverage
Basic Dental Care – Adult
Major Dental Care – Adult
Orthodontia – Adult
Accidental Dental	$130 Copay
Home and Nursing Care
Home Health Care Services	No Charge
Skilled Nursing Care - Facility	$1500 Copay per Day
Rehabilitative and habilitative services
Habilitation Services	$60 Copay
Outpatient Rehabilitation Services	$60 Copay
Rehabilitative Occupational and Rehabilitative Physical Therapy	$60 Copay
Rehabilitative Speech Therapy	$60 Copay
Other Services
Is HSA Eligible?	No
Allergy Testing	$60 Copay
Chemotherapy	$130 Copay
Chiropractic	$60 Copay
Diabetes Education	No Charge
Dialysis	$150 Copay
Durable Medical Equipment	$130 Copay
Hospice Service	No Charge
Infusion Therapy
Nutritional Counseling	$60 Copay
Prosthetic Devices	$130 Copay
Radiation	$130 Copay
Reconstructive Surgery	$150 Copay
Routine Foot Care
Treatment for Temporomandibular Joint Disorders	$130 Copay
Transplant	$150 Copay
Weight Loss Programs
Wellness Programs
Asthma Program	Available
Heart Disease Program	Available
Depression Program	Available
Diabetes Program	Available
High Blood Pressure & Cholesterol Program	Available
Low Back Pain Program	Not Available
Pain Management Program	Not Available
Pregnancy Program	Not Available
Weight Loss Programs	Not Available
Out-of-Network - See Summary of Benefits and Coverage	View Summary of Benefits and Coverage