Blue Community Silver 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	75605NM0390108-03
CSR Variation Type	Limited Cost Sharing Plan Variation
Insurance Company	Blue Cross and Blue Shield of New Mexico
Plan Type	HMO
Plan Metal Level	Silver
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.)	$1,700
Extra Deductible for Drugs
Doctor Visits
Doctor Visit - Preventive Care	No Charge
Doctor Visit - Primary Care	30% Coinsurance after deductible
Doctor Visit - Specialist	40% Coinsurance after deductible
Doctor Visit - Well Baby Visits and Care	30% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	40% Coinsurance after deductible
Hospital
Inpatient Hospital Facility	$850 Copay per Stay with deductible
Inpatient Hospital Physician/Surgeon	40% Coinsurance after deductible
Outpatient Hospital Facility	$600 Copay with deductible
Outpatient Hospital Physician/Surgeon	$200 Copay with deductible
Inpatient Maternity Services	$850 Copay with deductible
Emergency
Emergency Room Services	$1000 Copay with deductible
Emergency Medical Transportation	40% Coinsurance after deductible
Urgent Care Centers or Facilities	40% Coinsurance after deductible
Drugs
Plan's Drug Formulary	View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy	20% Coinsurance after deductible
Preferred Brand Drug on Formulary in a Local Pharmacy	30% Coinsurance after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy	35% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy	45% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work)	30% Coinsurance after deductible
X-Rays	30% Coinsurance after deductible
Imaging (CT/PET Scans, MRI, etc)	30% Coinsurance after deductible
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services	$850 Copay per Stay with deductible
Mental/Behavioral Health Outpatient Services	40% Coinsurance after deductible
Substance Use Disorder Inpatient	$850 Copay per Stay with deductible
Substance Use Disorder Outpatient	40% Coinsurance after deductible
Vision/Hearing Aids
Routine Eye Exam for Child	No Charge
Eye Glasses for Child	No Charge
Routine Eye Exam - Adult
Hearing Aids	40% Coinsurance 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	40% Coinsurance after deductible
Home and Nursing Care
Home Health Care Services	40% Coinsurance after deductible
Skilled Nursing Care - Facility	40% Coinsurance after deductible
Rehabilitative and habilitative services
Habilitation Services	40% Coinsurance after deductible
Outpatient Rehabilitation Services	40% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	40% Coinsurance after deductible
Rehabilitative Speech Therapy	40% Coinsurance after deductible
Other Services
Is HSA Eligible?	No
Allergy Testing	40% Coinsurance after deductible
Chemotherapy	40% Coinsurance after deductible
Chiropractic	40% Coinsurance after deductible
Diabetes Education	40% Coinsurance after deductible
Dialysis	40% Coinsurance after deductible
Durable Medical Equipment	40% Coinsurance after deductible
Hospice Service	40% Coinsurance after deductible
Infusion Therapy	$100 Copay
Nutritional Counseling	40% Coinsurance after deductible
Prosthetic Devices	40% Coinsurance after deductible
Radiation	40% Coinsurance after deductible
Reconstructive Surgery	40% Coinsurance after deductible
Routine Foot Care
Treatment for Temporomandibular Joint Disorders	40% Coinsurance after deductible
Transplant	40% Coinsurance 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