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HMO PLAN DETAILS

Get to know the Network Blue^® New England Deductible with HRA plan. This plan covers care received from doctors, hospitals, and other providers in our New England network. The service area includes Massachusetts, Rhode Island, Vermont, Connecticut, New Hampshire, and Maine.

View Summary of Benefits

HERE’S WHAT YOU SHOULD KNOW

About getting care

You’re required to choose a primary care provider (PCP).

Referrals are needed to see specialists.

In-network preventive care is 100% covered.¹

Only care received from providers in our New England network is covered.

About your costs

It’s higher cost per paycheck but lower deductible, compared to the PPO plan.

Copay only for most medical services and for prescriptions.

You’ll be auto-enrolled into a health reimbursement arrangement (HRA), funded by Blue Cross contributions.

You can choose to enroll in a health care flexible spending account (FSA).

HMO COSTS

	Paycheck Contributions² for Annualized Base Salary < $80K	Paycheck Contributions² for Annualized Base Salary ≥ $80K	Deductible³	Out-of-Pocket Maximum
Individual	$53.47	$75.44	$1,350	$3,000
Individual +1	$106.42	$150.30	$2,700	$6,000
Family	$155.25	$220.40	$2,700	$6,000

Pharmacy

	Retail Pharmacy (1-Month Supply)	Mail Order Pharmacy (3-Month Supply)
Tier 1 (generic)^3,4	$15 copay, no deductible	$30 copay, no deductible
Tier 2 (brand)^3,4	$30 copay, no deductible	$60 copay, no deductible
Tier 3 (non-preferred brand)^3,4	$50 copay, no deductible	$150 copay, no deductible

How Payments Work with Our HMO Plan

Phase 1 - Start of the year

You share costs with Blue Cross for most services right away through copayments. For others, you pay 100% of the cost until you reach your deductible.

Phase 2 - After deductible is met

You pay a copay for most services, and some services are now covered fully by Blue Cross. This continues until you meet your out-of-pocket maximum.

Phase 3 - After out-of-pocket maximum is met

You owe nothing. Blue Cross pays 100% of the cost for eligible, in-network expenses for the rest of the year.

Have family coverage?

With this plan, you and each member of your family work toward the deductible amount as individuals. Copayments begin for all family members when any combination of individual family member expenses meets the family deductible amount.

Things to Consider

Your PCP is your main source for health care services. If you see another provider or specialist, you’ll need to get a referral from your PCP for the service to be covered by your plan. Please make sure to update your PCP ID number with Employee Services to avoid delay in payment of claims. Call 1-800-238-6616 or email [email protected].
This plan has a higher cost per paycheck but is offset by having a lower deductible and out-of-pocket maximum. It pairs with an HRA that can be used to pay for eligible medical and prescription drug expenses.
You have the option of electing a health care FSA that can be used for eligible medical, prescription drug, dental, and vision expenses.
If you elect a health care FSA for 2025, up to $640 of unused funds will roll over from your 2024 balance and be available to use in 2025.

Financial Accounts for HMO

	Health Reimbursement Arrangement (HRA)	Health Care FSA	Dependent Care FSA
How is this funded?	Blue Cross automatically enrolls you into an HRA and contributes a set amount	You have the option to enroll, and can contribute personal funds up to the annual maximum	You have the option to enroll, and can contribute personal funds up to the annual maximum
Contributions⁵ from Blue Cross	Individual: $400 Individual +1: $800 Family: $1,000	None	None
Contributions⁵ from You	Individual contributions not allowed	Projected to be $3,300, but is subject to change pending Internal Revenue Service (IRS) confirmation	$5,000 per household or $2,500 if you’re married but filing separately
Who Can I Use This Money For?	You, your spouse, any covered tax dependents enrolled in the plan⁵	You, your spouse, your tax dependents (including children up to age 26) whether they’re enrolled in the plan or not⁵	Your children under age 13, a disabled spouse, or adult dependent — whether they’re enrolled in the plan or not⁵
What Can I Use This Money For?	All eligible^6,7 medical and prescription drug expenses in the plan year⁸	All eligible^6,7 medical, prescription drug, dental, and vision expenses in the plan year⁸	Childcare and adult day care expenses while you and your spouse work or attend school
What Happens to My Account Balance at the End of the Year?	Your unused balance is forfeited and doesn’t roll over to the next year. “Use it or lose it.”	If you elect a health care FSA for 2025, up to $640 of your unused balance from 2024 will roll over	Your unused balance won't roll over
What Happens to My Account if I Leave Blue Cross?	Your account is closed. You can file claims up to 90 days after your termination date for services received while you were working at Blue Cross.	Your account is closed. You can file claims up to 90 days after your termination date for services received while you were working at Blue Cross.	Your account is closed. You can file claims up to 90 days after your termination date for services received while you were working at Blue Cross.

1. Diagnostic tests and lab work aren't covered under preventive care.

2. Paycheck contribution amounts are for full-time associates. For part-time rates, download 2025 part-time rates.

3. The copay is waived for birth control (tier 1/generics only), smoking cessation drugs, and certain orally administered anti-cancer drugs.

4. These categories apply for most cases, but some medication tiers may vary.

5. Cannot be used for domestic partner expenses.

6. Eligible expenses include deductibles, co-insurance, and copayments where applicable.

7. Withdrawals for non-eligible expenses are subject to a tax penalty.

8. All expenses must be incurred in the plan year—January 1, 2025 to December 31, 2025. You can file claims for reimbursement through March 31, 2026.

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