PPO Enhanced Value Comparison

2007
In network

2007
Out of Network

Covered Services

Your Cost

Your Cost

Calendar-year deductible

None

$500 per member $1,000 per family

Calendar-year co-insurance maximum

None

$1,000 per member
$2,000 per family

Outpatient Care
Office Visits

$25 per visit

20% co insurance

Well-child care (age based schedule)

$25 per visit

20% co insurance

Routine Checkups (including one GYN exam per calendar year)

$25 per visit

20% co insurance

Maternity care

$25 per visit

20% co insurance

X-rays, lab test and other tests

Nothing

20% co-insurance

Emergency Room visits

$100 per visit (waived if observation or admitted)

$100 per visit (waived if observation or admitted)

Allergy injection only

$25 per visit

20% co insurance

Routine Hearing exam

$25 per visit

20% co insurance

One routine vision exam (every 24 months)

$25 per visit

20% co insurance

Family planning

$25 per visit

20% co insurance

Infertility services

$25 per visit

20% co insurance

Short-term rehabilitation therapy (up to 100 visits per calendar year)

$25 per visit

20% co insurance

Speech, hearing and language disorder treatment (speech therapy)

$25 per visit

20% co insurance

Home Health care and hospice care

Nothing

20% co-insurance

Durable medical equipment (such as wheelchairs, crutches, hospital beds) Covered to a maximum payment of $750 per calendar year

Charges beyond the calendar-year maximum

20% co-insurance and charges beyond the calendar-year maximum

Oxygen and equipment for its administration

Nothing

20% co-insurance

Prosthetic devices

Nothing

20% co-insurance

Surgery
Office setting
Ambulatory

$25 per visit
$250 per visit

20% co-insurance
20% co-insurance

In patient Care (including maternity care)
Hospital care (as many days as medically necessary)

$500 per admission

20% co-insurance

Care in a skilled nursing facility (up to 100 days per calendar year)

Nothing

20% co-insurance

Care in a rehabilitation hospital (up to 60 days per calendar year)

Nothing

20% co-insurance

Prescription Drug Benefit
At designated retail pharmacies
(up to 30 days formulary supply for each prescription /refill or supply)

$15 for generic
$30 for preferred
$50 for non preferred

$15 for generic
$30 for preferred
$50 for non preferred

Through Mail service drug program
(up to a 90 day formulary supply for each prescription/refill or supply)

$30 for generic
$60 for preferred
$100 for non preferred
90 day supply

$30 for generic
$60 for preferred
$100 for non preferred
90 day supply

Mental Health and Substance Abuse Treatment
Biologically based conditions

$500 per admission

20% co-insurance

Outpatient visits

$25 per visit

20% co insurance

Non-biologically based mental conditions
(included drug addition and alcoholism)
inpatient admissions in general hospital

$500 per admission

20% co-insurance

Inpatient admissions in a mental hospital or substance abuse treatment facility (up to 60 days per calendar year)

$500 per admission

20% co-insurance

Outpatient visits (up to 24 visits per calendar year)

$25 per visit

20% co insurance

Alcoholism treatment (in addition to non-biologically based mental conditions)
Inpatient admission in a general hospital

$500 per admission

20% co-insurance

Inpatient admissions in a substance abuse treatment facility
(up to 30 days per calendar year)

$500 per admission

20% co-insurance

Outpatient visits (up to 8 visits per calendar year)

$25 per visit

20% co insurance

Health Blue Programs

Living Health Babies

No Charge

No Charge

A Fitness Benefit toward membership at a heal club (see your subscriber certificate for details)

$150 per year; per individual/family

$150 per year; per individual/family

Reimbursement for a Blue Cross Blue Shield of Massachusetts designated weight loss program

$150 per year; per individual/family

$150 per year; per individual/family

Living Health Vision-discounts on eyewear
(frames, lenses, supplies and laser vision correction surgery)

Discounts varies

Discounts varies

Discounts on safety helmets and home safety items

Discount varies

Discount varies

Living Health naturally – discounts on different types of complementary alternative medicines services such as acupuncture, massage therapy, nutritional counseling, personal training, Pilates, tai chi, and yoga

Up to 30% discount

Up to 30% discount

Blue Care Line to answer your health care questions 24 hours a day- call 1-888-247-Blue(2583)

No charge

No charge

Visit www.AHealthyMe.com for an around the clock health approach to fitness, family and fun

No charge

No charge

Member Self Service on bluecrossma.com – to help you mange your health care

No charge

No charge