New Mexico
(HMO) H3251-002
(PPO) H8634-010
In-Network
Out of Network
Plan Premium
$0
$0
Doctors Office Visits
Primary Care Provider
$0
$0
$35 copay
Specialist
$50 copay
$45 copay
$55 copay
Maximum Out-of-Pocket
$4,500
$6,000
$11,300
Inpatient Hospital Copay
$325/day (days 1-5)
$335/day (days 1-6)
50% coinsurance
Retail Preferred Pharmacy
$0-$10/$10-$20/$47/$100/30%
Full coverage of Tier 1 in gap
Full coverage of Tier 1 in gap
$0-$10/$10-$20/$47/$100/29%
Full coverage of Tier 1 in gap
Full coverage of Tier 1 in gap
Prescription Drug Deductible
$150 (Tiers 4-5)
$200 (Tiers 4-5)
Extra Health & Wellness Benefits
Optional Supplemental Benefits Premium
$29.40
$33.00
Dental
Preventive
$0 copay (routine eye exam) 1 per year 2 exams, 2 cleanings, 1 x-ray
OSB Premier (Dental, Vision, Hearing)
Comprehensive
OSB Plus (Comp Dental, Eyewear, Hearing Aids)
OSB Premier (Dental, Vision, Hearing)
Vision
Eye Wear
OSB (Comp Dental, Eye Wear, Hearing Aids)
OSB Premier (Dental, Vision, Hearing) $0 copay (routine eye exam) 1 per year
Eye Exam
$0 copay (routine eye exam) yearly
OSB Premier (Dental, Vision, Hearing) $0 copay (routine eye exam) 1 per year
Hearing Aids
OSB (Comp Dental, Eye Wear, Hearing Aids)
OSB Premier (Dental, Vision, Hearing)
Over-The-Counter (OTC) Purchase Allowance
$100/Quarterly
$30/Quarterly
Not Covered
Silver Sneakers Fitness Program
✓
✓
24/7 Nurse Line
✓
✓
Transportation
12 one-way trips
Not Covered
Rewards
✓
✓
Telehealth
MD Live $0 copay Urgent Care Only
MD Live $0 copay Urgent Care Only
