Clear Cost Silver Plan – HMO

87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $12 copay
Specialist visit: $35 copay
Urgent care visit: $35 copay

SKU: 75605NM039025205 Category:

Description

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

Health Care Plan Details

Network type HMO
Deductible $1,100 per person $1,100 per person
Out-of-pocket max $2,950 per person $5,900 per family
Metal tier Silver

Visit Copay

Primary care visit $12 copay
Specialist visit $35 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $35 copay
Emergency room $105 copay after deductible
Ambulance $35 copay
Hospital stay (facility) $105 copay per Stay after deductible
Hospital stay (physician) $85 copay
Outpatient procedure (facility) $85 copay
Outpatient procedure (physician) $85 copay
Physical rehabilitation $12 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $105 copay after deductible

Pharmacy, Drugs, and Medication

Generic $8 copay
Brand $15 copay
Non-preferred Brand $100 copay after deductible
Specialty $65 copay

Lab Tests and Diagnostic Procedures

X-rays $35 copay
Imaging (CT/PET/MRI) $35 copay
Blood work $35 copay

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-sh5d05cnninmp-nm-2024.pdf
Drug and medication plan formulary https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_NM_5T_HIE.pdf
Search doctor list https://my.providerfinderonline.com/?ci=nm-bluecommunityhmo&corp_code=NM