Blue Community Security HMO

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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	75605NM0390105-01
CSR Variation Type	Standard Catastrophic On Exchange Plan
Insurance Company	Blue Cross and Blue Shield of New Mexico
Plan Type	HMO
Plan Metal Level	Catastrophic
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.)	$8,550
Extra Deductible for Drugs
Doctor Visits
Doctor Visit - Preventive Care	No Charge
Doctor Visit - Primary Care	$20 Copay
Doctor Visit - Specialist	No Charge after deductible
Doctor Visit - Well Baby Visits and Care	No Charge after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	No Charge after deductible
Hospital
Inpatient Hospital Facility	No Charge after deductible
Inpatient Hospital Physician/Surgeon	No Charge after deductible
Outpatient Hospital Facility	No Charge after deductible
Outpatient Hospital Physician/Surgeon	No Charge after deductible
Inpatient Maternity Services	No Charge after deductible
Emergency
Emergency Room Services	No Charge after deductible
Emergency Medical Transportation	No Charge after deductible
Urgent Care Centers or Facilities	No Charge after deductible
Drugs
Plan's Drug Formulary	View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy	No Charge after deductible
Preferred Brand Drug on Formulary in a Local Pharmacy	No Charge after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy	No Charge after deductible
Specialty Drug on Formulary in a Local Pharmacy	No Charge after deductible
Tests & Imaging
Diagnostic Tests (Blood work)	No Charge after deductible
X-Rays	No Charge after deductible
Imaging (CT/PET Scans, MRI, etc)	No Charge after deductible
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services	No Charge after deductible
Mental/Behavioral Health Outpatient Services	No Charge after deductible
Substance Use Disorder Inpatient	No Charge after deductible
Substance Use Disorder Outpatient	No Charge after deductible
Vision/Hearing Aids
Routine Eye Exam for Child	No Charge
Eye Glasses for Child	No Charge after deductible
Routine Eye Exam - Adult
Hearing Aids	No Charge after deductible
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	No Charge after deductible
Home and Nursing Care
Home Health Care Services	No Charge after deductible
Skilled Nursing Care - Facility	No Charge after deductible
Rehabilitative and habilitative services
Habilitation Services	No Charge after deductible
Outpatient Rehabilitation Services	No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	No Charge after deductible
Rehabilitative Speech Therapy	No Charge after deductible
Other Services
Is HSA Eligible?	No
Allergy Testing	No Charge after deductible
Chemotherapy	No Charge after deductible
Chiropractic	No Charge after deductible
Diabetes Education	No Charge after deductible
Dialysis	No Charge after deductible
Durable Medical Equipment	No Charge after deductible
Hospice Service	No Charge after deductible
Infusion Therapy	No Charge after deductible
Nutritional Counseling	No Charge after deductible
Prosthetic Devices	No Charge after deductible
Radiation	No Charge after deductible
Reconstructive Surgery	No Charge after deductible
Routine Foot Care
Treatment for Temporomandibular Joint Disorders	No Charge after deductible
Transplant	No Charge after deductible
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	Available
Pain Management Program	Available
Pregnancy Program	Available
Weight Loss Programs	Not Available
Out-of-Network - See Summary of Benefits and Coverage	View Summary of Benefits and Coverage