$40/$3,000 Deductible Plan NM1,2,3
| Features | Member pays |
| Medical calendar-year deductible (Individual Plan / Family Plan) | $3,000 / No dependent coverage |
| Annual out-of-pocket maximum (Individual Plan / Family Plan) | $6,000 / No dependent coverage |
| Lifetime benefit maximum (Individual) | $5 million |
| Professional services (plan provider office visits) | |
| Primary and specialty care visits (includes routine and urgent care appointments) | $40 per visit |
| Routine preventive physical exams (includes vision and hearing exams) |
$40 per visit |
| Well-child visits from 0 to 23 months | $30 per visit |
| Family planning visits | $40 per visit |
| Scheduled prenatal care | Not covered |
| Maternity coverage | |
| Maternity care | Not covered |
| Hospitalization services | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and medications | 20% coinsurance (after deductible) |
| Emergency health coverage | |
| Emergency Department visits (charge waived if admitted directly to the hospital) |
$150 per visit (after deductible) |
| Ambulance services | |
| Emergency ambulance services | $150 per trip (after deductible) |
| Prescriptions | |
| Plan pharmacy (up to a 30-day supply) | Generic: $10; brand-name: $35 |
| Mail-order (up to a 100-day supply) | Generic: $20; brand-name: $70 |
| Outpatient services | |
| Outpatient surgery | 20% coinsurance (after deductible) |
| Allergy injection visits | $5 per visit (after deductible) |
| Vaccines (immunizations) | No charge |
| Most x-rays and lab tests | $10 per encounter (after deductible) |
| MRI, CT, and PET | $50 per procedure (after deductible) |
| Note: Deductible does not apply to preventive screenings as described in the Certificate of Insurance. | |
| Mental health services | |
| Inpatient psychiatric care (up to 30 days) | 20% coinsurance (after deductible) |
| Outpatient individual psychiatric visits | $40 per visit |
| Outpatient group psychiatric visits | $20 per visit |
| Outpatient individual/group visits per calendar year | Up to a total of 20 visits |
| Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the Certificate of Insurance. | |
| Chemical dependency services | |
| Inpatient detoxification | 20% coinsurance (after deductible) |
| Outpatient individual therapy visits | $40 per visit |
| Outpatient group therapy visits | $5 per visit |
| Transitional residential recovery services (up to 60 days, not to exceed 120 days in any five-year period) |
$100 per admission (after deductible) |
| Home health services | |
| Home health care (up to 100 two-hour visits) |
No charge |
| Health education | |
| Individual visits | $40 per visit |
| Group visits | No charge |
| Other | |
| Skilled Nursing Facility care (up to 100 days per benefit period) |
20% coinsurance (after deductible) |
| Hospice care | No charge |
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