Medical Plans | Blue Cross Blue Shield of Massachusetts

Payment Details

KeyIndividualIndividual +1Family

Network Blue New England Deductible (HMO)

Blue Care Elect Saver—Choice (PPO)
PPO Summary of Benefits

Network Blue New England Deductible (HMO)
HMO Summary of Benefits

	(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

Annual salary <$70K

Annual salary ≥$70K

$1,125

$750

$400

$2,250

$1,500

$800

$2,250

$1,500

$1,000

Net Deductible The remaining balance of your deductible after using Blue Cross contributions

(PPO)

(HMO)

Annual salary <$70K

Annual salary ≥$70K

$375

$750

$850

$750

$1,500

$1,700

$750

$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 Costs

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 copay¹	$150 copay, no deductible¹
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 deductible³

Hospital Care

	(PPO)	(HMO)
Inpatient/Outpatient	deductible, then co-insurance²	deductible, then $0¹

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 copay^{2, 4}

Mental/Behavioral Health or Substance Use Disorder

	(PPO)	(HMO)
Inpatient	deductible, then co-insurance²	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

Telehealth

	(PPO)	(HMO)
Minor medical care	deductible, then co-insurance for medical care	$25 copay for medical care
Therapy	deductible, then co-insurance for therapy	$25 copay for therapy
Psychiatry	deductible, then co-insurance for psychiatry	$25 copay for psychiatry

WE’VE WAIVED COPAYS, CO-INSURANCE, AND DEDUCTIBLES FOR TELEHEALTH SERVICES FOR THE DURATION OF THE MASSACHUSETTS PUBLIC HEALTH EMERGENCY.

1. Copay waived if admitted or for observation stay.

2. Prior authorization required.

3. Under this plan, you're required to select a PCP and will need a referral from your PCP to see a specialist.

4. 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.