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Blue Community Bronze HMOSM 201 - Off Exchange
Plan Summary
Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
Find Doctors 		$100 Copay
Office Visit for Specialist $160 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $160 Copay
Annual Deductible Individual: $8,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 50%
Retail Prescription Drugs Generic Drugs: $10 Copay;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 35% Coinsurance after deductible;
Specialty Drugs: 45% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $9,200
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. 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. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $750 Copay with deductible, then 50% Coinsurance after deductible
Emergency Ambulance Services 50% Coinsurance after deductible
Urgent Care Facility $60 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $10 Copay;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 35% Coinsurance after deductible;
Specialty Drugs: 45% Coinsurance after deductible;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$200 Copay with deductible, then 50% Coinsurance after deductible
Outpatient Facility Fee:
$600 Copay with deductible, then 50% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
$60 Copay
X-rays:
$150 Copay
Imaging (CT and PET scans, MRIs) 50% Coinsurance after deductible
Outpatient Mental Health No Charge
Outpatient Substance Abuse No Charge
Outpatient Rehabilitation Services (PT, OT, ST) $100 Copay
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$850 Copay per Stay with deductible, then 50% Coinsurance after deductible
Inpatient Physician and Surgical Services:
50% Coinsurance after deductible
Skilled Nursing Facility 50% Coinsurance after deductible, limited to 60 Days per Benefit Period
Inpatient Mental Health No Charge
Inpatient Substance Abuse No Charge
Home Healthcare 50% Coinsurance after deductible, limited to 100 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit $100 Copay
Labor & Delivery Hospital Stay $850 Copay with deductible, then 50% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge, limited to 1 Visit(s) per Benefit Period
Eye Glasses for Children No Charge, limited to 1 Item(s) per Benefit Period
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $100 Copay, limited to 20 Visit(s) per Benefit Period
Durable Medical Equipment 50% Coinsurance after deductible
Hospice 50% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A+ as of 10/31/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • - EHealthInsurance Services, 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.
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