Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Your PCP, OB/GYN physician, network nurse practitioner or nurse midwife • Other network providers $20 per visit, no deductible $60 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible Mental health or substance abuse treatment $10 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Your PCP or OB/GYN physician • Other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) in: • Other general hospitals (as many days as medically necessary) • Higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your Choice
Appears in 8 contracts
Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Benefits Routine hearing exams Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Your by your PCP, OB/GYN physicianGYN, network nurse practitioner practitioner, or nurse midwife • Other When performed by other network providers $20 per visit, no deductible $60 35 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible Mental health or and substance abuse treatment $10 15 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays and rays, lab tests, and other tests, excluding CT scansCTscans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office• Office setting – When performed by your PCP, when OB-GYN, nurse practitioner, or nurse midwife – When performed by: • Your PCP or OB/GYN physician • Other by other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory • Ambulatory surgical facility, hospital outpatient departmenthospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible Inpatient Care care (including maternity care) in: • Other In other general hospitals (as many days as medically necessary) • Higher In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible† $1,500 700 per admission after deductible† Mental hospital and substance abuse facility care (as many days as medically necessary) $200 per admission after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your Choice
Appears in 4 contracts
Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Your PCP, OB/GYN physician, network nurse practitioner or nurse midwife • Other network providers $20 per visit, no deductible $60 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible Mental health or substance abuse treatment $10 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Your PCP or OB/GYN physician • Other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) in: • Other general hospitals (as many days as medically necessary) • Higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your ChoiceChoice Your Deductible MIIA PPO Benchmark Plan v.3 7/1/2022 – 6/30/2024 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield of Massachusetts. Your deductible is $500 per member (or $1,000 per family) for in-network services and $500 per member (or $1,000 per family) for out-of-network services. Your deductible for prescription drugs is $100 per member (or $200 per family). When You Choose Preferred Providers You receive the highest level of benefits under your health care plan when you obtain covered services from preferred providers. These are called your est level of benefits. This plan has two levels of hospital benefits for preferred providers. You will pay a higher cost share when you receive certain inpatient services at or by “higher cost share hospitals.” See the charts for your cost share. Note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you are referred to is not a preferred provider, yourvices (such as a specialist), make sure the provider is a preferredices at or by “higher cost share hospitals.” See the charts for your co you. Your cost will be greater when you receive certain inpatient services at or by the higher cost share hospitals listed below, even if your preferred provider refers you. Higher Cost Share Hospitals Your cost share will be higher at the hospitals listed below. Blue Cross Blue Shield of Massachusetts will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • UMass Memorial Medical Center Note: Some of the general hospitals listed above may have facilities in more than one location. At certain locations, the lowest cost sharing level may apply. How to Find a Preferred Provider There are a few ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call the Physician Selection Service at 0-000-000-0000 You can also obtain covered services from non-preferred providers, but your out-of-pocket costs are higher. These are called your “ouriders, but your out-of-pocket costs are hi network benefits are based on the Blue Cross Blue Shield allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s actual billed charge (this is in addition to your deductible and/or your coinsurance). See the charts for your cost share. Your Out-of-Pocket Maximum Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical benefits is $2,500 per member (or $5,000 per family) for in- network and out-of-network services combined. Your out-of- pocket maximum for prescription drug benefits is $1,000 per member (or $2,000 per family).
Appears in 2 contracts
Samples: Agreement, Collective Bargaining Agreement
Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Benefits Routine hearing exams Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Your by your PCP, OB/GYN physicianGYN, network nurse practitioner practitioner, or nurse midwife • Other When performed by other network providers $20 per visit, no deductible $60 35 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible Mental health or and substance abuse treatment $10 15 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office• Office setting – When performed by your PCP, when OB-GYN, nurse practitioner, or nurse midwife – When performed by: • Your PCP or OB/GYN physician • Other by other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory • Ambulatory surgical facility, hospital outpatient departmenthospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible Inpatient Care care (including maternity care) in: • Other In other general hospitals (as many days as medically necessary) • Higher In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible† $1,500 700 per admission after deductible† Mental hospital and substance abuse facility care (as many days as medically necessary) $200 per admission after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your Choice
Appears in 2 contracts
Samples: Agreement, Collective Bargaining Agreement
Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Benefits Routine hearing exams Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Your by your PCP, OB/GYN physicianGYN, network nurse practitioner practitioner, or nurse midwife • Other When performed by other network providers $20 per visit, no deductible $60 35 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible Mental health or and substance abuse treatment $10 15 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an office• Office setting – When performed by your PCP, when OB-GYN, nurse practitioner, or nurse midwife – When performed by: • Your PCP or OB/GYN physician • Other by other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory • Ambulatory surgical facility, hospital outpatient departmenthospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible Inpatient Care care (including maternity care) in: • Other In other general hospitals (as many days as medically necessary) • Higher In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible† $1,500 700 per admission after deductible† Mental hospital and substanceabuse facility care (as many days as medically necessary) $200 per admission after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your Choice
Appears in 2 contracts
Covered Services Your Cost. Preventive Care Well-child care visits Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Benefits Routine hearing exams Nothing, no deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when visits When performed by: • Your by your PCP, OB/GYN physicianGYN, network nurse practitioner practitioner, or nurse midwife • Other When performed by other network providers $20 per visit, no deductible $60 35 per visit, no deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible Mental health or and substance abuse treatment $10 15 per visit, no deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** Prosthetic devices Nothing after deductible Surgery and related anesthesia in an officeOffice setting – When performed by your PCP, when OB-GYN, nurse practitioner, or nurse midwife – When performed by: • Your PCP or OB/GYN physician • Other by other network providers $20 per visit***, no deductible $60 per visit***, no deductible Surgery in an ambulatory Ambulatory surgical facility, hospital outpatient departmenthospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible Inpatient Care care (including maternity care) in: • Other In other general hospitals (as many days as medically necessary) • Higher In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible† $1,500 700 per admission after deductible† Mental hospital and substanceabuse facility care (as many days as medically necessary) $200 per admission after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. † This cost share copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost** At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Your Choice
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Samples: Agreement
