HMO Blue New England Options v.4 Deductible Plan

This health plan includes a tiered provider network called HMO Blue New England Options v.4. Members in this plan pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of the provider furnishing the services. A provider’s benefits tier may change. Overall changes to the benefits tiers of providers will happen no more than once each calendar year. For help in finding the benefits tier of a provider, visit the online provider search tool at www.bluecrossma.com and search for HMO Blue New England Options v.4.

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HMO Blue NE Options v.4 Deductible Plan

• Use HMO Blue New England Network Providers

• Choose PCP - Change Effective 1st of Month

• Referrals to Network Specialists

• No Referrals For: OB/GYN, Chiropractic or Outpatient Behavioral Health Visits, Routine Vision Exam, Emergency or Out-of-Area Urgent Care

HMO Blue NE Options v.4 Deductible Plan

• Supports Our Promise to Put Our Members’ Health First

• Provides Cost Share Incentives to Encourage Use of High-Quality, Lower-Cost Providers

• Plan Design Encourages You to Become More Engaged in Making Health Care Decisions

• You Can Control What You Pay For PCP Visits & Hospital Services

HMO Blue NE Options v.4 Deductible PlanPCPs & General Hospitals in Massachusetts Network*

Ranked in 3 Benefit Tiers: • Enhanced

- Hospitals and PCPs that meet the standards for quality and low cost.

- You Pay Lowest Cost Share

• Standard

- Hospitals and PCPs that meet the standards for quality and moderate cost. Hospitals that do not meet the standards for quality but meet the standards for low or moderate cost. 

- You Pay Standard Cost Share

• Basic

- Scored Below Benchmarks For Quality and/or Moderate Cost

- You Pay Highest Cost Share

*Providers in NH, ME, VT, RI & CT Covered as Enhanced

Find Your Providers’ Tiers

• Go to Blue Options Resource Center at www.bluecrossma.com/blueoptions/ or Call Member Service

- Find Provider’s Tier

- Find How Provider Scored on Each

Benchmark

- Find PCP’s Hospital Affiliations

Preventive Visits

Preventive Visits, Related Tests & Immunizations Covered in Full – No Copayment!

• Well-Child Care Visits

• Routine Adult Physical Exams

• Routine GYN Exams

• Routine Vision Exams

• Routine Hearing Exams

• Family Planning Services - Office Visits

Tiered Benefits

• PCP Office Visits

- $15/$25/$50

• Plan-Year Deductible (General Hospital Services Only)

- Enhanced Hospitals: No Deductible

- Standard Hospitals: $500/$1,000

- Basic Hospitals: $2,000/$4,000

General Hospital Benefits

• General Hospital Inpatient & Surgical Day Care Admissions

- $150/$150*/$1,000*• Emergency Room Visits/Admissions: $150

(Any Hospital)• General Hospital Outpatient MRIs, Nuclear

Cardiac Imaging Tests, PET & CT Scans

- $50/$50*/$450*

* After Deductible

General Hospital Benefits

• General Hospital Outpatient Chemotherapy, Radiation Therapy & Dialysis

- Nothing/Nothing/Nothing (No Deductible)• General Hospital Outpatient Physical,

Occupational, Speech Therapy & Cardiac Rehabilitation

- $50/$50/$50 (No Deductible)• Other General Hospital Tests & Medical Visits

- Nothing/Nothing*/Nothing*

* After Deductible

Other Services Not Tiered

• Outpatient Behavioral Health Visits: $15

• All Other Outpatient Professional Providers’ & Specialists’ Visits: $50

• Outpatient MRIs, Nuclear Cardiac Imaging Tests, PET & CT Scans (At Other Than a General Hospital): $50

• Day Surgery at an Ambulatory Surgical Facility (At Other Than a General Hospital): $150

Other Services Not Tiered

• Inpatient Admissions to Chronic Disease, Mental Health & Substance Abuse Treatment Hospitals: $150

• Retail Rx: $15/$30/$50

• Mail Service Rx: $30/$60/$150

• All Other Services Covered in Full

Out-of-Pocket Maximum

$5,000/$10,000 Plan-Year Out-of-Pocket Maximum

Includes:

• Deductible

• Copayments Over $100 (Except Rx)

Considerations

• PCP’s Tier

• Covering PCP’s Tier

• PCP’s Hospital Affiliations

• Hospitals Used by Specialists to Whom PCP Refers

• Go to www.bluecrossma.com/blueoptions/

or Call Member Service to find a new PCP

Healthier Living

• $150 Fitness Benefit

• $150 Weight Loss Benefit

• Living Healthy Babies!

• Childbirth Class Benefit

• Blue Care Line: 1-888-247-BLUE (2583)

• Blue365 – Health & Wellness Resources/Discounts

• Living Healthy Vision Discounts

• Living Healthy Naturally Discounts

• Safe Beginnings Discounts

Member Central Account

www.bluecrossma.com

Create an Online Account, Then You Can:

• Change Your PCP

• Request an ID Card

• Review Your Benefits

• Review Your Claims

• Enroll in My Blue Health

Questions?

For Provider Information or Questions About Membership, Benefits, Referrals or Claims Call Member Service Number on ID Card

Monday - Friday, 8 a.m.- 6 p.m.

or Visit www.bluecrossma.com