1. HMO Blue New England Options v.4 Deductible Plan
Thank you for taking the time to review your new HMO Blue New England Options version 4 Deductible plan.
This health plan includes a tiered provider network called HMO Blue New England Options v.4. Members in this plan pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of the provider furnishing the services. A provider’s benefits tier may change. Overall changes to the benefits tiers of providers will happen no more than once each calendar year. For help in finding the benefits tier of a provider, visit the online provider search tool at and search for HMO Blue New England Options v.4.

2. HMO Blue NE Options v.4 Deductible Plan
Use HMO Blue New England Network Providers
Choose PCP - Change Effective 1st of Month
Referrals to Network Specialists
No Referrals For: OB/GYN, Chiropractic or Outpatient Behavioral Health Visits, Routine Vision Exam, Emergency or Out-of-Area Urgent Care
Benefits are available for services you receive from network providers. The HMO Blue New England network includes all hospitals in all 6 New England states – MA, NH, ME, VT, CT & RI - and most of the doctors in those states. Each family member chooses a primary care physician and can change doctors during the year. PCP changes are effective the 1st of the month after you notify us. Your PCP will refer you to a network specialist when you need specialty care but you don’t need referrals for ob/gyn, chiropractic or outpatient behavioral health visits, or for a routine vision exam. Just be sure to choose a network provider for those services. In an emergency, you should go to the nearest hospital emergency room for treatment. If you are traveling or have a student attending school outside of MA, you are covered for any emergency or sudden illness anywhere in the world. 2

3. HMO Blue NE Options v.4 Deductible Plan
Supports Our Promise to Put Our Members’ Health First
Provides Cost Share Incentives to Encourage Use of High- Quality, Lower-Cost Providers
Plan Design Encourages You to Become More Engaged in Making Health Care Decisions
You Can Control What You Pay For PCP Visits & Hospital Services
The HMO Blue New England Options Deductible Plan supports our promise to always put our members’ health first. It provides cost share incentives to encourage our members to use high-quality, lower-cost providers. The plan design encourages you to become more engaged with your doctor in making health care decisions. You can control what you pay for primary care physician visits and for general hospital services.

4. HMO Blue NE Options v.4 Deductible Plan
PCPs & General Hospitals in Massachusetts Network* Ranked in 3 Benefit Tiers:
Enhanced
- Hospitals and PCPs that meet the standards for quality and low cost.
- You Pay Lowest Cost Share
Standard
- Hospitals and PCPs that meet the standards for quality and moderate cost. Hospitals that do not meet the standards for quality but meet the standards for low or moderate cost. 
- You Pay Standard Cost Share
Basic
- Scored Below Benchmarks For Quality and/or Moderate Cost
- You Pay Highest Cost Share
*Providers in NH, ME, VT, RI & CT Covered as Enhanced
General, acute care hospitals and primary care physicians in the Massachusetts network have been placed into one of 3 benefit levels or tiers based on the quality of the care they provide and what they charge for their services. We are not, at this time, tiering providers in the other 5 New England States. PCPs & general hospitals are reviewed periodically and may change tiers but you will use version 4 tiering throughout your plan year. When you receive care, the amount you pay is based on your provider’s tier. Hospitals & PCPs in our enhanced benefits tier have met our benchmarks for quality and for lowest cost. When you receive services from enhanced providers, you pay the lowest cost share. Six hospitals are included in the standard benefits tier in order to provide geographic access for our members. These hospitals are Baystate Franklin Medical Center, Baystate Mary Lane Hospital, Falmouth Hospital, Martha’s Vineyard Hospital, Nantucket Cottage Hospital, and North Adams Regional Hospital. For services by Standard Benefits Tier providers you pay the standard cost share. If you are using providers in the network of another New England state, your services will be covered at the enhanced level. But if your PCP should refer you to MA network providers for care, your benefits will be based on the MA provider’s tier.

5. Find Your Providers’ Tiers
Go to Blue Options Resource Center at or Call Member Service
- Find Provider’s Tier
- Find How Provider Scored on Each
Benchmark
- Find PCP’s Hospital Affiliations
To find your provider’s tier, go to our Blue Options Resource Center at You can then search for your PCP and find his or her tier and how the provider scored on each benchmark. You can also call the Member Service toll free number on the back of your summary of benefits and speak to one of our representatives. You can also find out which hospitals your PCP uses and the tiers of those hospitals. PCPs are tiered separately and are not related to the hospitals’ tiers.

6. Preventive Visits
Preventive Visits, Related Tests & Immunizations Covered in Full – No Copayment!
Well-Child Care Visits
Routine Adult Physical Exams
Routine GYN Exams
Routine Vision Exams
Routine Hearing Exams
Family Planning Services - Office Visits
For all preventive visits to any network provider, including related tests & immunizations, you will pay nothing. These services are covered in full with no copayment and include well-child care visits, routine adult physical exams, routine GYN exams, routine vision & hearing exams and office visits for family planning services.

7. Tiered Benefits PCP Office Visits - $15/$25/$50
Plan-Year Deductible (General Hospital Services Only)
- Enhanced Hospitals: No Deductible
- Standard Hospitals: $500/$1,000
- Basic Hospitals: $2,000/$4,000
The summary of benefits includes a detailed description of the HMO Blue New England Options Deductible plan benefits, but we will review the cost sharing here. As I mentioned earlier, routine preventive visits to your PCP are covered in full. But for other office visits, the copayment that you pay for services by your network primary care physician is based on your PCP’s tier. For office visits to an PCP in the Enhanced benefits tier, you pay a $15 copayment. The copayment for a visit to a standard benefits tier PCP is $25 and $50 for a basic benefits tier PCP. Any other services that are billed by your primary care physician are covered in full. The deductible under this plan applies only to services you receive at a Standard or Basic general hospital. There is no deductible for services you receive at or that are billed by an enhanced benefits tier hospital or for services by any other provider. The deductible for services billed by a Standard Benefits tier hospital is $500 for each member each plan year but will not be more than $1,000 for an entire family. At a Basic Benefits tier hospital, the deductible is $2,000 for each member but will not be more than $4,000 for the family. Any portion of the deductible that is met on either tier will be applied to both the standard and the basic deductibles. For example, a member who receives services at a standard benefits tier hospital must meet the $500 deductible. If that member then receives services at a Basic benefits tier hospital, there is only $1,500 of the $2,000 basic deductible left to meet. Please note that the deductible is waived for those 4 hospitals mentioned earlier that are in the standard benefits tier to provide geographic access.

8. General Hospital Benefits
General Hospital Inpatient & Surgical Day Care Admissions
- $150/$150*/$1,000*
Emergency Room Visits/Admissions: $150 (Any Hospital)
General Hospital Outpatient MRIs, Nuclear Cardiac Imaging Tests, PET & CT Scans
- $50/$50*/$450*
* After Deductible
For general hospital inpatient or surgical day care admissions, you pay a $150 copayment in an enhanced hospital or a $150 copayment after your deductible in a standard hospital. A $200 copayment with no deductible applies in the 4 geographic access hospitals. For these services you pay a $1,000 copayment after the deductible in a basic benefits tier hospital. The plan pays the rest of the hospital bill and all of the physicians’ charges. If you have to go to the emergency room, go to the nearest hospital and don’t worry about the hospital’s tier. Emergency room visits or admissions from the emergency room at any hospital are covered in full less a $150 copayment. For outpatient high technology imaging tests which include MRIs, nuclear cardiac imaging tests and PET & CT scans, you pay a $50 copayment in an enhanced hospital, $50 after the deductible in a standard hospital and $450 after the deductible in a Basic hospital.

9. General Hospital Benefits
General Hospital Outpatient Chemotherapy, Radiation Therapy & Dialysis
- Nothing/Nothing/Nothing (No Deductible)
General Hospital Outpatient Physical, Occupational, Speech Therapy & Cardiac Rehabilitation
- $50/$50/$50 (No Deductible)
Other General Hospital Tests & Medical Visits
- Nothing/Nothing*/Nothing*
* After Deductible
Outpatient chemotherapy, radiation therapy & dialysis services at any network hospital (regardless of that hospital’s tier) are covered in full with no deductible. Outpatient physical, occupational or speech therapy and cardiac rehabilitation services at any network hospital have a $50 copayment but there is no deductible. For other services billed by a general hospital such as lab work, x-rays and medical visits, you have full coverage at an enhanced hospital and full coverage after the deductible at either a standard or basic hospital.

10. Other Services Not Tiered
Outpatient Behavioral Health Visits: $15
All Other Outpatient Professional Providers’ & Specialists’ Visits: $50
Outpatient MRIs, Nuclear Cardiac Imaging Tests, PET & CT Scans (At Other Than a General Hospital): $50
Day Surgery at an Ambulatory Surgical Facility (At Other Than a General Hospital): $150
Services by all other network providers are not tiered. For outpatient behavioral health visits to any network provider, you pay a $15 copayment. Outpatient office visits to all other professional providers, including physical therapists & chiropractors and office visits to all specialists have a $50 copayment. Other services billed by these providers are covered in full. For outpatient high tech imaging tests at a network facility other than a general hospital, such as a Shield’s MRI center, you pay a $50 copayment. If you go to an ambulatory surgical facility instead of a general hospital for day surgery, you pay a $150 copayment.

11. Other Services Not Tiered
Inpatient Admissions to Chronic Disease, Mental Health & Substance Abuse Treatment Hospitals: $150
Retail Rx: $15/$30/$50
Mail Service Rx: $30/$60/$150
All Other Services Covered in Full
For inpatient admissions to any network chronic disease, mental health and substance abuse treatment hospitals, you are responsible for a $150 copayment and the plan pays the rest of the facility’s bill and all of the physicians’ charges. For prescriptions purchased at a retail pharmacy, you will pay no more than the cost of your medication and no more than a copayment for a 30-day supply. For tier 1, which includes most generic drugs, you pay no more than $15. For tier 2 preferred drugs, your copayment is $30 and for tier 3 non-preferred drugs, your copayment is $50. For maintenance medication that you take for more than a few months, you are able to get a 90-day supply at one time through our Express Scripts mail service pharmacy and can save on tiers 1 & 2 drugs. For those medications you pay 2 copayments for each 90-day supply. You do have to pay 3 copays for a 90-day supply of non-preferred tier 3 medications. Please go to our website, or call Member Service at the toll-free number on the back of the benefit summary to find the tiers for your medications and instructions for using the mail service pharmacy. If you find that any of your medications are subject to our pharmacy guidelines, be sure to call the prescribing physician and let him or her know. For all other covered services under the plan, you pay nothing.

12. Out-of-Pocket Maximum
$5,000/$10,000 Plan-Year Out-of-Pocket Maximum
Includes:
Deductible
Copayments Over $100 (Except Rx)
If your deductible and copayments that are more than $100 (except prescriptions) should reach $5,000 during the plan year for one member, or $10,000 for the entire family, for the remainder of that plan year all of those services will be covered in full. You would still be responsible for your prescription copayments and copays that are less than $100.

13. Considerations PCP’s Tier Covering PCP’s Tier
PCP’s Hospital Affiliations
Hospitals Used by Specialists to Whom PCP Refers
Go to
or Call Member Service to find a new PCP
What are the things you need to consider to ensure that you use high quality, lower-cost providers? You first need to find how your PCP scored on quality & cost. It’s important not only to know your PCP’s tier but also the tier of PCPs who cover for your doctor when he or she is not available. If your PCP is part of a group practice, all of the PCPs in that group are on the same tier as your PCP. You will want to know the hospitals where your PCP has admitting privileges. And you will want to know which hospitals are used by the specialists to whom your PCP refers. If you decide that you want to change your primary care physician and need some assistance finding a PCP in a particular tier who admits to a particular hospital, you can go to our website or call Blue Cross Blue Shield Member Service.

14. Healthier Living $150 Fitness Benefit $150 Weight Loss Benefit
Living Healthy Babies!
Childbirth Class Benefit
Blue Care Line: BLUE (2583)
Blue365 – Health & Wellness Resources/Discounts
Living Healthy Vision Discounts
Living Healthy Naturally Discounts
Safe Beginnings Discounts
We offer additional benefits to encourage you to maintain or improve your overall health. Detailed information about all of these benefits is included in your enrollment materials and on our web site. You are eligible for a $150 reward each calendar year per family toward a membership to any health or fitness club. An additional $150 reward is available each calendar year per family toward the cost of any hospital-based weight-loss program or a Weight Watchers retail or at-work program. We offer the Living Healthy Babies program (which includes a reimbursement toward the cost of childbirth classes) to provide information and support to new parents. Medical advice from a registered nurse is available 24 hours a day by calling our Blue Care Line toll-free number. There is no charge for this service and our members who call the Blue Care Line have eliminated many unnecessary emergency room visits. Carrying the Blue Cross Blue Shield ID card gives you access to some great discounts for vision correction and alternative medicine, including acupuncture, massage therapy, nutritional counseling, yoga, Pilates, Tai Chi and personal trainers. To take advantage of these discounts, call us or go to our web site and find a provider in your area who has agreed to give the discount and, when you go, show them your Blue Cross Blue Shield ID card. Discounts are also available for child and home safety items.

15. Member Central Account www.bluecrossma.com
Create an Online Account, Then You Can:
Change Your PCP
Request an ID Card
Review Your Benefits
Review Your Claims
Enroll in My Blue Health
You can go to our web site, bluecrossma.com, and set up a Member Central online account. This will give you access to your membership information. You can confirm who’s covered under your plan and change your primary care physician. If you lose your ID card you can request a new one. You will be able to access the HMO Blue New England Options Deductible Plan Subscriber Certificate for the complete details of your plan. You will also be able to access all of your claims. And by enrolling in My Blue Health, you will have access to our many web-based wellness programs.

16. or Visit www.bluecrossma.com
Questions?
For Provider Information or Questions About Membership, Benefits, Referrals or Claims Call Member Service Number on ID Card
Monday - Friday, 8 a.m.- 6 p.m.
or Visit
If you need provider information or wish to speak with a Blue Cross Blue Shield Member Service representative about your membership, referrals, benefits or claims, please call Member Service between 8 a.m. and 6 p.m. You can visit our web site anytime. We look forward to meeting all of your health care needs. And thank you, again, for taking the time to review your new medical plan.