Payment Details1
Key
|
Blue Care Elect Saver—Choice (PPO) |
Network Blue New England Deductible (HMO) |
| (PPO) | (HMO) |
|---|
Annual Deductible
| (PPO) | (HMO) | |
|---|---|---|
|
|
$1,500 | $1,250 |
|
|
$3,000 | $2,500 |
|
|
$3,000 | $2,500 |
Contributions from Blue Cross
| (PPO) | (HMO) | |||
|---|---|---|---|---|
|
HSA |
HRA | |||
|
||||
|
|
|
$400 | ||
|
|
|
$800 | ||
|
|
|
$1,000 |
Net Deductible The remaining balance of your deductible after using Blue Cross contributions
| (PPO) | (HMO) | |||
|---|---|---|---|---|
|
||||
|
|
|
$850 | ||
|
|
|
$1,700 | ||
|
|
|
$1,500 |
Out-of-Pocket Maximum
| (PPO) | (HMO) | |
|---|---|---|
|
|
$5,000 | $3,000 |
|
|
$10,000 | $6,000 |
|
|
$10,000 | $6,000 |
A Blue Cross-funded account is automatically paired with each medical plan to help offset a portion of your annual deductible.
How to determine your Net Deductible
Example:
Pat needs family coverage and has an annual salary of less than $70,000.
Based on the rates in the chart above, see how he would find the Net Deductible for each plan.
| PPO Plan | HMO Plan | |
|---|---|---|
| Annual Deductible | $3,000 | $2,500 |
| Subtract Contributions by Blue Cross | $2,250 | $1,000 |
| Net Deductible | $750 | $1,500 |
Medical Services Costs1
|
Blue Care Elect Saver—Choice (PPO) |
Network Blue New England Deductible (HMO) |
| (PPO) | (HMO) |
|---|
Co-insurance/Copayments
| (PPO) | (HMO) | |
|---|---|---|
| You must meet the deductible amount first, then you’ll only pay 10% co-insurance (when required) | $25-$150 copayments (specific services subject to deductible) |
Medical
| (PPO) | (HMO) | |
|---|---|---|
| Preventive Care | $0, no deductible | $0, no deductible |
| ER |
deductible, then $150 copay2 |
$150 copay, no deductible2 |
| Urgent Care | deductible, then co-insurance | $35 copay, no deductible |
| PCP Visit | deductible, then co-insurance |
$25 copay, no deductible |
| Specialist Visit | deductible, then co-insurance |
$35 copay, no deductible4 |
Hospital Care
| (PPO) | (HMO) | |
|---|---|---|
| Inpatient/Outpatient |
deductible, then co-insurance3 |
deductible, then $02 |
Tests
| (PPO) | (HMO) | |
|---|---|---|
| Diagnostics (X-rays, lab tests) | deductible, then co-insurance | deductible, then $0 |
| Imaging (CT/PET scans, MRIs) | deductible, then co-insurance |
deductible, then $75 copay3, 5 |
Behavioral Health or Substance Use Disorder
| (PPO) | (HMO) | |
|---|---|---|
| Inpatient |
deductible, then co-insurance3 |
deductible, then $0 |
| Outpatient | deductible, then co-insurance | $25 copay, no deductible |
Pregnancy Care
| (PPO) | (HMO) | |
|---|---|---|
| Prenatal | $0, no deductible | $0, no deductible |
| Postnatal | deductible, then co-insurance | $0, no deductible |
| Inpatient (including delivery) | deductible, then co-insurance | deductible, then $0 |
1. For part-time plan rates download the 2020 part-time rates PDF
2. Copay waived if admitted or for observation stay.
3. Prior authorization required.
4. Under this plan you're required to select a PCP and will need a referral from your PCP to see a specialist.
5. Change and cost-sharing limitations and/or exceptions may apply. For more information, review the overview of benefits and coverage under each medical plan option.