BlueCross BlueShield of New Mexico

Blue Community Silver HMO 203 - On Exchange

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Medical Deductible	Individual: $1,800 Family: $3,600 Per Person: $1,800
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Primary Doctor	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible \| Explanation: When services are provided via telehealth, cost shares may vary. Please see benefit booklet for details.
Specialist	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible \| Explanation:

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible \| Explanation: 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.
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 35.00% Coinsurance after deductible \| Explanation: 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.
Generic Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible \| Explanation: 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.
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 45.00% Coinsurance after deductible \| Explanation: 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.

Hospital Services	Standard: Copay: $850.00 Copay per Stay with deductible \| Coinsurance: 40.00% Coinsurance after deductible \| Explanation: 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.
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible \| Explanation:

Emergency Room

Standard: Copay: $1000.00 Copay with deductible | Coinsurance: 40.00% Coinsurance after deductible | Explanation: 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.

HealthMarkets Insurance Agency d/b/a Insphere Insurance Solutions, Inc is an independent, authorized agent for Blue Cross and Blue Shield of New Mexico.
Blue Cross and Blue Shield of New Mexico: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Effective dates are available on the first of the month only, unless otherwise required by law. Applications must be received by Blue Cross and Blue Shield of New Mexico within the defined enrollment period to be accepted.