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HMO Blue Deductible with Copayment Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services Coverage Period: on or after 01/01/2020 HMO Blue Deductible with Copayment Coverage for: Individual and Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see bluecrossma.com/connector. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at bluecrossma.com/sbcglossary or call 1-800-262-BLUE (2583) to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan What is the overall begins to pay. If you have other family members on the plan, each family member must meet their own $2,000 member / $4,000 family. deductible? individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Yes. Preventive care, prenatal This plan covers some items and services even if you haven’t yet met the deductible amount. But a Are there services care, most office visits, generic copayment or coinsurance may apply. For example, this plan covers certain preventive services without covered before you meet prescription drugs, mental health cost sharing and before you meet your deductible. See a list of covered preventive services at your deductible? visits, and therapy visits. https://www.healthcare.gov/coverage/preventive-care-benefits/. Yes. For preferred and non- Are there other preferred prescription drugs, $250 You must pay all of the costs for these services up to the specific deductible amount before this plan deductibles for specific member / $500 family. There are begins to pay for these services. services? no other specific deductibles. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family What is the out-of-pocket $5,250 member / $10,500 family. members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of- limit for this plan? pocket limit has been met. Premiums, balance-billing What is not included in charges, and health care this plan Even though you pay these expenses, they don't count toward the out-of-pocket limit. the out-of-pocket limit? doesn't cover. Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will bluecrossma.com/findadoctor or pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the Will you pay less if you call the Member Service number difference between the provider’s charge and what your plan pays (balance billing). Be aware, your use a network provider? on your ID card for a list of network provider might use an out-of-network provider for some services (such as lab work). Check with network providers. your provider before you get services. Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services but only if you have a Yes. see a specialist? referral before you see the specialist. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Limitations, Exceptions, & Other Services You May Need In-Network Out-of-Network Medical Event (You will pay the (You will pay the Important Information least) most) Primary care visit to treat an injury or illness $30 / visit Not covered None $55 / visit; $55 / Limited to 12 acupuncture visits per Specialist visit chiropractor visit; $55 Not covered calendar year / acupuncture visit If you visit a health care GYN exam limited to one exam per provider’s office or clinic calendar year. You may have to pay for services that aren't preventive. Ask Preventive care/screening/immunization No charge Not covered your provider if the services needed are preventive. Then check what your plan will pay for. Deductible applies first; copayment $75 for x-rays and applies per category of test / day; Diagnostic test (x-ray, blood work) Not covered $50 for lab tests pre-authorization required for certain services If you have a test Deductible applies first; copayment applies per category of test / day; Imaging (CT/PET scans, MRIs) $300 Not covered pre-authorization required for certain services $25 / retail supply or Generic drugs $50 / mail order Not covered supply Deductible applies first except for generic drugs; up to 30-day retail (90- If you need drugs to treat $50 / retail supply or day mail order) supply; cost share may your illness or condition Preferred brand drugs $100 / mail order Not covered be waived for certain covered drugs supply More information about and supplies; pre-authorization prescription drug coverage $125 / retail supply or required for certain drugs is available at Non-preferred brand drugs $375 / mail order Not covered bluecrossma.com/medicatio supply ns Deductible applies first except for Applicable cost share generic drugs; when obtained from a Specialty drugs (generic, preferred, Not covered designated specialty pharmacy; pre- non-preferred) authorization required for certain drugs 2 of 7 What You Will Pay Common Limitations, Exceptions, & Other Services You May Need In-Network Out-of-Network Medical Event (You will pay the (You will pay the Important Information least) most) Deductible applies first; Facility fee (e.g., ambulatory surgery center) $500 / admission Not covered pre-authorization required for certain If you have outpatient services surgery Deductible applies first; Physician/surgeon fees No charge Not covered pre-authorization required for certain services Deductible applies first; copayment Emergency room care $350 / visit $350 / visit waived if admitted or for observation If you need immediate stay medical attention Emergency medical transportation No charge No charge Deductible applies first Out-of-network coverage limited to out Urgent care $55 / visit $55 / visit of service area Deductible applies first; Facility fee (e.g., hospital room) $750 / admission Not covered pre-authorization required If you have a hospital stay Deductible applies first; Physician/surgeon fees No charge Not covered pre-authorization required Pre-authorization required for certain Outpatient services $30 / visit Not covered If you need mental health, services behavioral health, or Deductible applies first; substance abuse services Inpatient services $750 / admission Not covered pre-authorization required for certain services Office visits No charge Not covered Deductible applies first except for Childbirth/delivery professional services No charge Not covered prenatal care; cost sharing does not apply for preventive services; If you are pregnant maternity care may include tests and Childbirth/delivery facility services $750 / admission Not covered services described elsewhere in the SBC (i.e. ultrasound) 3 of 7 What You Will Pay Common Limitations, Exceptions, & Other Services You May Need In-Network Out-of-Network Medical Event (You will pay the (You will pay the Important Information least) most) Deductible applies first; Home health care No charge Not covered pre-authorization required Limited to 60 visits per calendar year (other than for autism, home health Rehabilitation services $55 / visit Not covered care, and speech therapy); pre-authorization required for certain services Limited to 60 visits per calendar year (other than for autism, home health care, and speech therapy); cost share If you need help recovering Habilitation services $55 / visit Not covered and coverage limits waived for early or have other special health intervention services for eligible needs children; pre-authorization may be required for certain services Deductible applies first; limited to 100 Skilled nursing care $750 / admission Not covered days per calendar year; pre-authorization required Deductible applies first; cost share Durable medical equipment 20% coinsurance Not covered waived for one breast pump per birth Deductible applies first; Hospice services No charge Not covered pre-authorization required for certain services Limited to one exam every 12 months Children’s eye exam No charge Not covered until the end of the month a member turns age 19 Deductible applies first; limited to one set of prescription lenses and / or If your child needs dental or Children’s glasses 35% coinsurance Not covered frames or contact lenses per calendar eye care year until the end of the month a member turns age 19 Limited to twice per calendar year until Children’s dental check-up No charge Not covered the end of the month a member turns age 19 4 of 7 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Long-term care • Private-duty nursing • Dental care (Adult) • Non-emergency care when traveling outside the U.S. Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Abortion • Chiropractic care • Routine eye care - adult (one exam every 24 months) • Acupuncture (12 visits per calendar year) • Hearing aids ($2,000 per ear every 36 months • Routine foot care (only for patients with systemic • Bariatric surgery for members age 21 or younger) circulatory disease) • Infertility treatment • Weight loss programs ($150 per calendar year per policy) 5 of 7 Your Rights to Continue Coverage: If you have Individual health insurance: There are agencies that can help if you want to continue your coverage after it ends.
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