Your Deductible. Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for some benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductible is $250 per member (or $750 per family). Your Out-of-Pocket Maximum. Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical benefits is $2,500 per member (or $5,000 per family). Your out- of-pocket maximum for prescription drug benefits is $1,000 per member (or $2,000 per family).
Your Deductible. Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield of Massachusetts. Your deductible is $500 per member (or $1,000 per family) for in-network services and $500 per member (or $1,000 per family) for out-of-network services. Your deductible for prescription drugs is $100 per member (or $200 per family). When You Choose Preferred Providers You receive the highest level of benefits under your health care plan when you obtain covered services from preferred providers. These are called your “in-network” benefits. This plan has two levels of hospital benefits for preferred providers. You will pay a higher cost share when you receive certain inpatient services at or by “higher cost share hospitals.” See the charts for your cost share. Note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you are referred to is not a preferred provider, you’re still covered, but your benefits, in most situations, will be covered at the out- of-network level–even if the preferred provider refers you. Your cost will be greater when you receive certain inpatient services at or by the higher cost share hospitals listed below, even if your preferred provider refers you. Higher Cost Share Hospitals Your cost share will be higher at the hospitals listed below. Blue Cross Blue Shield of Massachusetts will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • UMass Memorial Medical Center Note: Some of the general hospitals listed above may have facilities in more than one location. At certain locations, the lowest cost sharing level may apply. How to Find a Preferred Provider There are a few ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call the Physician Selection Service at 0-000-000-0000 When You Choose Non-Preferred Providers You can also obtain covered services f...
Your Deductible. Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $250 per member (or $750 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose Preferred Providers. The plan has two levels of hospital benefits for preferred providers. You will pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you are referred to is not a preferred provider, you’re still covered, but your benefits, in most situations, will be covered at the out-of- network level, even if the preferred provider refers you. It is also important to check whether the provider you are referred to is affiliated with one of the higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, even if your preferred provider refers you.
Your Deductible. A. The Deductible is the portion of the Costs that You must pay for each Breakdown as indicated in Section 1. When no Deductible amount is indicated in Section 1, then Your Deductible will be zero dollars ($0). Your Deductible does not apply to Rental Car, Towing, Manufacturer’s Warranty Deductible, Emergency Road Service or Travel Lodging coverages.
Your Deductible. The deductible is the annual amount you pay – using your HSA or out-of-pocket – before you reach the traditional health coverage portion of the plan. Annual Deductible Responsibility In Network $2,000 individual coverage $4,000* family coverage *This plan includes a family deductible, which means that the medical expenses of all fail members count toward the deductible. Once the full deductible has been satisfied, all family members are covered under the Traditional Health Coverage portion of the plan. If needed - Traditional Health Coverage After you meet your deductible, you pay coinsurance (a percentage of the provider’s charges) when you visit a network provider. You’ll pay more if you visit an out-of- network provider. Your traditional health coverage begins: Traditional Health Coverage After your deductible, the plan pays: 100% for network providers 70% for out-of-network providers After your deductible, your coinsurance responsibility is: 0% for network providers 30% for out-of-network providers Rx Retail and Mail: Deductible and Coinsurance up to your annual out-of-pocket maximum Additional protection: For your protection, the total amount you spend out of your pocket is limited. Once you spend that amount, the plan pays 100% of the cost for covered services for the remainder of the benefit year. Annual Out-of-Pocket Maximum Network Providers Out-of-Network Providers $2,000 individual coverage $4,000 individual coverage $4,000 family coverage $8,000 family coverage Your annual out-of-pocket maximum consists of your annual deductible responsibility and your coinsurance amounts. SISA1137P1 (Core SISA1137PY) Manchester School District 7/1/13 version 5/15/13 1 of 4 If you have questions, please call toll-free 0-000-000-0000. BlueChoiceTM New England Regional HSA (NH, VT, MA, ME, CT and RI) Lumenos Plan Summary Tools and Personalized Services You will have access to our award-winning online health site and the following programs to help you reach your health potential: • MyHealth Assessment: You and your family members can complete the MyHealth Assessment, our online tool designed to help measure your overall health. The health information you provide is strictly confidential.
