Blue Community Silver HMO℠ 204

75605NM0390094
Silver
HMO

Blue Community Silver HMO℠ 204 is a Silver HMO plan by Blue Cross and Blue Shield of New Mexico.

Locations

Blue Community Silver HMO℠ 204 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Blue Community Silver HMO℠ 204 75605NM0390094.
Insurer: Blue Cross and Blue Shield of New Mexico
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 75605NM0390094

Cost-Sharing Overview

Blue Community Silver HMO℠ 204 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Community Silver HMO℠ 204?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Community Silver HMO℠ 204 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Community Silver HMO℠ 204 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Coverage outside our service area is available for Emergency and Urgent Care services only.
National Network: No

Additional Benefits and Cost-Sharing

Blue Community Silver HMO℠ 204 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable.
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered in the instances of rape, incest, and life endangerment.
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Benefit Period Unless for Habilitative and Rehabilitative ServicesSubstantially Equal
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covers diagnosis and medically indicated treatments for physical conditions causing infertility.
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Weight Loss Programs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dietary evaluations and counseling for the medical management of morbid obesity and obesity are covered
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 3 Years Limit is per hearing impaired ear and limited to covered members up to age 21.
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered: The following are covered benefits: Nutritional supplements for prenatal care when prescribed by a practitioner/provider are covered for pregnant women.; Nutritional counseling as medically necessary; Nutritional supplements that require a prescription to be dispensed are covered when prescribed by a Practitioner/Provider and when medically necessary to replace a specific documented deficiency.; Nutritional supplements administered by injection at the practitioner’s/provider’s office are covered when medically necessary.; Enteral formulas or products, as nutritional support, are covered only when prescribed by a practitioner/provider and administered by enteral tube feedings.; Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is covered when ordered by a practitioner/provider.; Special medical foods as listed as covered benefits in the Genetic Inborn Errors of Metabolism (IEM) benefit or as medically necessary.; Not Covered: The following are not covered: Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings.; Nutritional supplements prescribed by an attending practitioner/provider not due to a deficiency or as the sole source of nutrition.
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Benefit Period Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.Substantially Equal
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable.
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable.
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable.
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions.
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Visit(s) per Benefit Period Substantially Equal
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Days per Benefit Period Preauthorization may be required. See benefit booklet for details.Substantially Equal
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details.Substantially Equal
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Community Silver HMO℠ 204 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Blue Community Silver HMO℠ 204?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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