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HMO Blue New England $1,000 Deductible Plan-Year Deductible: $1,000/$2,000

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SUMMARY OF BENEFITS HMO Blue New England $1,000 Deductible Plan-Year Deductible: $1,000/$2,000 DBC Pri-Med LLC This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that
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SUMMARY OF BENEFITS HMO Blue New England $1,000 Deductible Plan-Year Deductible: $1,000/$2,000 DBC Pri-Med LLC This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. An Association of Independent Blue Cross and Blue Shield Plans Your Care Your Primary Care Provider (PCP) When you enroll in HMO Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at consult the Provider Directory; or call the Physician Selection Service at If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office. Referrals Your PCP is the first person you call when you need routine or sick care. If your PCP decides that you need to see a specialist for covered services, your PCP will refer you to an appropriate network specialist, who is likely affiliated with your PCP s hospital or medical group. You will not need prior authorization or referral to see a HMO Blue New England network provider who specializes in OB/GYN services. Your providers may also work with Blue Cross Blue Shield of Massachusetts regarding referrals and Utilization Review Requirements, including Pre-Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services, and Individual Case Management. For detailed information about Utilization Review, see your subscriber certificate. 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 $1,000 per member (or $2,000 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 (including prescription drug copaymetns), and coinsurance for covered services. Your out-of-pocket maximum is $2,000 per member (or $4,000 per family). Emergency Room Services In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). You pay a copayment per visit for emergency room services. This copayment is waived if you re admitted to the hospital or for an observation stay. See the chart on the opposite page for your cost share. Telehealth Services You are covered for certain medical and behavioral health services for conditions that can be treated through video visits from an approved Telehealth provider. These Telehealth services are available by using your computer or mobile device when you prefer not to make an in-person visit for any reason to a doctor or therapist. For a list of Telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at consult the Provider Directory; or call the Physician Selection Service at Service Area The plan s service area includes all cities and towns in the Commonwealth of Massachusetts, State of Rhode Island, State of Vermont, State of Connecticut, State of New Hampshire, and State of Maine. When Outside the Service Area If you re traveling outside the service area and you need urgent or emergency care, you should go to the nearest appropriate health care facility. You are covered for the urgent or emergency care visit and one follow-up visit while outside the service area. Any additional follow-up care must be arranged by your PCP. See your subscriber certificate for more information. Dependent Benefits This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your subscriber certificate (and riders, if any) for exact coverage details. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information. Your Medical Benefits Covered Services Preventive Care Well-child care visits Routine adult physical exams, including related tests Routine GYN exams, including related lab tests (one per calendar year) Routine hearing exams Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) Routine vision exams (one every 24 months) Family planning services office visits Outpatient Care Emergency room visits Office visits, when performed by: Your PCP, OB/GYN physician, network nurse practitioner or nurse midwife Other network providers Chiropractors office visits Mental health or substance abuse treatment Short-term rehabilitation therapy physical and occupational (up to 60 visits per calendar year*) Speech, hearing, and language disorder treatment speech therapy Diagnostic X-rays and lab tests, including CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Home health care and hospice services Oxygen and equipment for its administration Durable medical equipment such as wheelchairs, crutches, hospital beds Prosthetic devices Surgery and related anesthesia in an office, when performed by: Your PCP or OB/GYN physician Other network providers Surgery in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit Your Cost All charges beyond the maximum, no deductible $150 per visit, no deductible (waived if admitted or for observation stay) $20 per visit, no deductible $35 per visit, no deductible $35 per visit, no deductible $20 per visit, no deductible $35 per visit after deductible $35 per visit after deductible 20% coinsurance after deductible** 20% coinsurance after deductible $20 per visit***, no deductible $35 per visit***, no deductible Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Mental hospital or substance abuse facility care (as many days as medically necessary) Rehabilitation hospital care (up to 60 days per calendar year) Skilled nursing facility care (up to 100 days per calendar year) * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Deductible waived for mental health admissions. Prescription Drug Benefits* At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) * Tier 1 generally refers to generic drugs; Tier 2 generally refers to preferred brand-name drugs; Tier 3 refers to non-preferred drugs. ** Cost share may be waived for certain covered drugs and supplies. Your Cost** No deductible $15 for Tier 1 $30 for Tier 2 $50 for Tier 3 No deductible $30 for Tier 1 $60 for Tier 2 $150 for Tier 3 Get the Most from Your Plan Visit us at or call to learn about discounts, savings, resources, and special programs available to you, like those listed below. A Fitness Benefit toward membership at a health club or for fitness classes This fitness benefit applies for fees paid to: privately owned or privately sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your subscriber certificate for details.) A Weight Loss Program Benefit toward participation in a qualified weight loss program This weight loss program benefit applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your subscriber certificate for details.) Blue Care Line A 24-hour nurse line to answer your health care questions call BLUE (2583) Reimbursement for membership fees for up to 3 consecutive months of one annual family or individual membership at a health club or 10 fitness classes, per individual or family per calendar year Reimbursement for up to 3 months participation fees per individual or family per calendar year No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts, call , or visit us online at Interested in receiving information from us via ? Go to to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc BS (10/16) PDF KP Nondiscrimination Notice Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA ; phone at (TTY: 711); fax at ; or at If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at or (TDD). Complaint forms are available at hhs.gov. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc M (8/16) Translation Resources Proficiency of Language Assistance Services Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID Chinese/ 简体中文 : 注意 : 如果您讲中文, 我们可向您免费提供语言协助服务 请拨打您 ID 卡上的号码联系会员服务部 (TTY 号码 :711) Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711). Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711). :ةيرب/ Arabic انتباه: إذا كنت تتحدث اللغة العربية فتتوفر خدمات املساعدة اللغوية مجان ا بالنسبة لك. اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ه ويتك )جهاز الهاتف النيص للصم والبكم : TTY 711(. Mon-Khmer, Cambodian/ខ ម រ: ក រជ នដ ណ ង ប រស នប រ អ នកន យ យភ ស ខ ម រ ស វ ជ ន យភ ស ឥតគ តថ ល គ អ ចរកប នសបរ រ អ នក ស មទ រស ព ទទ ផ ន កស វ សម ជ កត មល ខ ន ប រ ណ ណ សម គ ល ល នរ រស អ នក (TTY: 711) French/Français: ATTENTION : si vous parlez français, des services d assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d assuré (TTY : 711). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa Korean/ 한국어 : 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 귀하의 ID 카드에있는전화번호 (TTY: 711) 를사용하여회원서비스에전화하십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze Hindi/ह द : ध य न द : यद आप ह न द ब लत ह, त भय षय स य तय स वय ए, आप क ल ए न :श लक उपलब ध ह सदस स वय ओ क आपक आई.ड. कय ड ड पर द ए गए न बर पर क ल कर (टद.टद.वय ई.: 711). Gujarati/ગ જર ત : ધ ય ન આપ : જ તમ ગ જરય ત બ લતય હ, ત તમન ભય ષય ક ય સહય તય સ વય ઓ વ નય મ લ ઉપલબ ધ છ. તમય રય આઈડ કય ડ ડ પર આપ લય ન બર પર Member Service ન ક લ કર Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card Japanese/ 日本語 : お知らせ : 日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください (TTY: 711) German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an :پارسیان/ Persian توج: اگر زبان شما فارسی است خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد. با شمار تلفن مندرج بر روی کارت شناسایی خود با بخش»خدمات اعضا«تماس بگیر ید )711.)TTY: Lao/ພາສາລາວ: ຂ ຄວນໃສ ໃຈ: ຖ າເຈ າເວ າພາສາລາວໄດ, ມການບ ລການຊ ວຍເຫ ອດ ານພາສາໃຫ ທ ານໂດຍ ບເສຍຄ າ. ໂທ ຫາ ຝ າຍບ ລການສະ ມາ ຊ ກທ ໝາຍເລກໂທລະສ ບຢ ໃນບ ດຂອງທ ານ Navajo/Diné Bizaad: BAA!KOHWIINDZIN DOO&G&: Din4 k ehj7 y1n7[t i go saad bee y1t i 47 t 11j77k e bee n7k1 a doowo[go 47 n1 ahoot i. D77 bee an7tah7g7 ninaaltsoos bine d44 n0omba bik1 7g7ij8 b44sh bee hod77lnih Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc MB (8/16)
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