Your Deductible. 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 “in-network” 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, you’re still covered, but your benefits, in most situations, will be covered at the out- of-network level–even if the preferred provider refers 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 When You Choose Non-Preferred Providers You can also obtain covered services from non-preferred providers, but your out-of-pocket costs are higher. These are called your “out-of-network” benefits. Payments for out-of 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).
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