HMO New England Enhanced Value |
2007 |
| |
|
Covered Services |
Your Cost |
Outpatient Care
Office Visits |
$25 per visit |
Well-child care
|
$25 per visit |
Routine Checkups (including one GYN exam per calendar year) |
$25 per visit |
Maternity care |
Nothing |
X-rays, lab test and other tests |
Nothing |
Hearing exams |
$25 per visit |
Vision exams (one per 24 month period) |
$25 per visit |
Emergency Room visits |
$100 (waived for observation stay or if admitted) |
Allergy injection only |
Nothing |
Family planning |
$25 per visit |
Infertility services |
$25 per visit
Nothing for surgical service |
Short-term rehabilitation therapy (up to 60 visits per calendar year) |
$25 per visit |
Speech, hearing and language disorder treatment (speech therapy) |
$25 per visit |
Home Health care and hospice care |
Nothing |
Chiropractor services |
$25 per visit |
Durable medical equipment (such as wheelchairs, crutches, hospital beds) Covered to a maximum payment of $750 per calendar year |
All charges beyond calendar-year benefit maximum |
Oxygen and equipment for its administration |
Nothing |
Prosthetic devices |
Nothing |
Ambulatory surgery (including infertility services) |
$250 per admission for outpatient day surgery |
| |
|
In patient Care (including maternity care)
Hospital care (as many days as medically necessary) |
$500 per admission
(within 30 days for same admission no more than $500) |
Care in a skilled nursing facility (up to 100 days per calendar year) |
Nothing |
Care in a rehabilitation hospital (up to 60 days per calendar year) |
Nothing |
| |
|
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 brand-name
$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 brand-name
$100 for non-preferred
(For 90 day supply) |
| |
|
Mental Health and Substance Abuse Treatment
Biologically based conditions |
$500 per admission |
Outpatient visits |
$25 per visit |
| |
|
Non-biologically based mental conditions
(included drug addition and alcoholism)
inpatient admissions in general hospital |
$500 per admission |
Inpatient admissions in a mental hospital or substance abuse treatment facility (up to 60 days per calendar year) |
$500 per admission |
Outpatient visits (up to 24 visits per calendar year) |
$25 per visit |
| |
|
Alcoholism treatment
(in addition to non-biologically based mental conditions)
Inpatient admission in a general hospital |
$500 per admission |
Inpatient admissions in a substance abuse treatment facility
(up to 30 days per calendar year) |
$500 per admission |
Outpatient visits (up to 8 visits per calendar year) |
$25 per visit |
|
|
Health Blue Programs |
|
Living Health Babies |
No Charge |
A Fitness Benefit toward membership at a heal club (see your subscriber certificate for details) |
$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 |
Living Health Vision-discounts on eyewear
(frames, lenses, supplies and laser vision correction surgery) |
Discounts varies |
Discounts on safety helmets and home safety items |
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 |
Blue Care Line to answer your health care questions 24 hours a day- call 1-888-247-Blue(2583) |
No charge |
Visit www.AHealthyMe.com for an around the clock health approach to fitness, family and fun |
No charge |
Member Self Service on bluecrossma.com - to help you mange your health care |
No charge |
Access Blue Enhanced Value Plan
|
2007 |
| |
|
Covered Services |
Your Cost |
Outpatient Care
Office Visits |
$10 per visit for PCP
$30 for all other plan providers |
Well-child care (age based schedule)
|
Nothing |
Routine Checkups (including one GYN exam per calendar year) |
Nothing |
Maternity care |
Nothing |
X-rays, lab test and other tests |
Nothing |
Hearing exams |
$10 per visit for PCP
$30 for all other plan providers |
Vision exams (one per 24 month period) |
$10 per visit |
Emergency Room visits |
$100 (waived for observation stay or if admitted) |
Allergy injection only |
Nothing |
Family planning |
$10 per visit for PCP
$30 for all other plan providers |
Infertility services |
$10 per visit
Nothing for surgical service |
Preventive dental care for children under age 12 (one visit each six months) |
Nothing |
Short-term rehabilitation therapy (up to 60 visits per calendar year) |
$30 per visit |
Speech, hearing and language disorder treatment (speech therapy) |
$10 per visit for PCP
$30 for all other plan providers |
Home Health care and hospice care |
Nothing |
Chiropractor services (up to 20 visits per year) |
$30 per visit |
Durable medical equipment (such as wheelchairs, crutches, hospital beds) Covered to a maximum payment of $750 per calendar year |
All charges beyond calendar-year benefit maximum |
Oxygen and equipment for its administration |
Nothing |
Prosthetic devices |
20% of approved charges |
Ambulatory surgery (including infertility services) |
$250 per admission for outpatient day surgery |
| |
|
In patient Care (including maternity care)
Hospital care (as many days as medically necessary) |
$500 per admission
(within 30 days for same admission no more than $500) |
Care in a skilled nursing facility (up to 100 days per calendar year) |
Nothing |
Care in a rehabilitation hospital (up to 60 days per calendar year) |
Nothing |
| |
|
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 brand-name
$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 brand-name
$100 for non-preferred
(For 90 day supply) |
| |
|
Mental Health and Substance Abuse Treatment
Biologically based conditions |
$500 per admission |
Outpatient visits |
$10 per visit |
| |
|
Non-biologically based mental conditions (included drug addition and alcoholism) inpatient admissions in general hospital |
$500 per admission |
Inpatient admissions in a mental hospital or substance abuse treatment facility (up to 60 days per calendar year) |
$500 per admission |
Outpatient visits (up to 24 visits per calendar year) |
$10 per visit |
| |
|
Alcoholism treatment
(in addition to non-biologically based mental conditions)
Inpatient admission in a general hospital |
$500 per admission |
Inpatient admissions in a substance abuse treatment facility
(up to 30 days per calendar year) |
$500 per admission |
Outpatient visits (up to 8 visits per calendar year) |
$10 per visit |
|
|
Health Blue Programs |
|
Living Health Babies |
No Charge |
A Fitness Benefit toward membership at a heal club (see your subscriber certificate for details) |
$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 |
Living Health Vision-discounts on eyewear(frames, lenses, supplies and laser vision correction surgery)
|
Discounts varies |
Discounts on safety helmets and home safety items |
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 |
Blue Care Line to answer your health care questions 24 hours a day- call 1-888-247-Blue(2583) |
No charge |
Visit www.AHealthyMe.com for an around the clock health approach to fitness, family and fun |
No charge |
Member Self Service on bluecrossma.com - to help you mange your health care |
No charge |
PPO Enhanced Value
|
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 |
