Blue Cross Blue Shield Plan
(employees in CT, MA, NH, RI only)
How it works
- This plan only covers services provided by in-network providers
- For certain services, such as doctor’s office visits, you pay a copay at the time of service.
- For other services, such as hospitalization, you’ll pay the full cost until you meet the annual deductible.
- Once the deductible is met, you and the plan share the cost of certain services through copays and coinsurance, until you meet your out of pocket maximum.
- You pay a copay for prescription drugs (with the exception of certain preventive drugs, which have no out-of-pocket costs when you use an in-network pharmacy).
- If you meet the out-of-pocket maximum, the plan pays 100% of your eligible expenses for the rest of the year.
Do you have a PCP?
With an HMO, you’re required to select a Primary Care Provider (PCP) who will manage your care and provide referrals if you need to see a specialist.
Contact Info
Documents
Key Features
Copays for most services.
You pay a copay for certain medical services (office visits, physical therapy, ER visits), instead of coinsurance.
Deductibles may apply.
You must satisfy a deductible for certain services (x-rays, labs, etc). Once this has been met, various copays or charges may apply.
Qualified in-network preventive care at no cost to you:
For example, you pay nothing out-of-pocket for in-network annual physicals, immunizations, routine cancer screenings and more.
Blue Cross Blue Shield Plan
| Blue Cross Blue Shield HMO | |
|---|---|
| In-Network | |
| Annual Deductible | |
| Individual | $1,000 |
| Family | $2,000 |
| Out of Pocket Maximum | |
| Individual | $4,000 Prescription Drugs: $1,000 |
| Family | $,8000 Prescription Drugs: $2,000 |
| Coinsurance | None |
| Services | |
| Preventive Care | Covered at 100% |
| Office Visit - PCP | $20 per visit (deductible does not apply) |
| Office Visit - Specialist | $40 per visit (deductible does not apply) |
| X-ray | No charge after deductible |
| Laboratory | No charge after deductible |
| Diagnostic Complex Imaging | No charge after deductible |
| Inpatient Hospitalization | No charge after deductible |
| Outpatient - Ambulatory Surgical Center | No charge after deductible |
| Outpatient - Hospital | No charge after deductible |
| Urgent Care | $40 per visit In-network & Out-of-network; Out-of-network coverage limited to out of service area; (deductible does not apply) |
| Emergency Room | $100 per visit (deductible does not apply) |
| Ambulance | No charge (deductible does not apply) |
| Physical Therapy | $40 / visit |
| Chiropractic | $40 / visit |
| Pharmacy - Retail | |
| Generic | $15 |
| Preferred | $30 |
| Non-Preferred | $50 |
| Pharmacy - Mail Order | |
| Generic | $30 |
| Preferred | $60 |
| Non-Preferred | $100 |
| Specialty Drugs | |
| Applicable cost share (generic, preferred, non-preferred) | |