Blue Community Silver HMO℠ 203 – HMO

87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: 20% coinsurance after deductible
Specialist visit: 30% coinsurance after deductible
Urgent care visit: 30% coinsurance after deductible

SKU: 75605NM039010905 Category:

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type HMO
Deductible $400 per person $400 per person
Out-of-pocket max $3,150 per person $6,300 per family
Metal tier Silver

Visit Copay

Primary care visit 20% coinsurance after deductible
Specialist visit 30% coinsurance after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care 30% coinsurance after deductible
Emergency room $500 copay after deductible, 30% coinsurance after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) $250 copay per Stay after deductible, 30% coinsurance after deductible
Hospital stay (physician) 30% coinsurance after deductible
Outpatient procedure (facility) $100 copay after deductible, 20% coinsurance after deductible
Outpatient procedure (physician) $50 copay after deductible, 30% coinsurance after deductible
Physical rehabilitation 30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $250 copay after deductible, 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic No charge after deductible
Brand 20% coinsurance after deductible
Non-preferred Brand 35% coinsurance after deductible
Specialty 45% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 20% coinsurance after deductible
Imaging (CT/PET/MRI) 20% coinsurance after deductible
Blood work 20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services No charge
Psychiatric hospital stay No charge

Health Plan Provider Information

Health Plan Benefits https://www.bcbsnm.com/sbc/ind/sbc-sh5h31cnninmp-nm-2024.pdf
Drug and medication plan formulary https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NM_6T_HIE.pdf
Search doctor list https://my.providerfinderonline.com/?ci=nm-bluecommunityhmo&corp_code=NM