BENEFITS GUIDE FY23: OPEN ENROLLMENT TOWN OF SHREWSBURY
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BENEFITS GUIDE FY23: OPEN ENROLLMENT TOWN OF SHREWSBURY CONTACT: NHAWES@SHREWSBURYMA.GOV 508-841-8318
Office of the TELEPHONE: (508) 841-8318
TOWN MANAGER FAX: (508) 841-8385
nhawes@shrewsburyma.gov
TOWN OF SHREWSBURY
100 Maple Avenue
Shrewsbury, Massachusetts 01545-5338
ATTN: Permanent-Benefit Eligible Employees working over 20 hours per week
Retirees under age 65 or not Medicare Eligible
The FY 2023 Open Enrollment period will take place beginning Monday, March 14th through Friday, April
15th. Each of the plan’s rates can be found in the Open Enrollment Guide or on the town website. Please
review this information to help you to determine which plan is right for you and your family.
The following will take place for Fiscal Year 2023:
Effective June 30, 2022, Fallon announced they will no longer be providing commercial health insurance
coverage. All members on an active employee or non-Medicare eligible retiree plan will have to change to a
different carrier’s plan. Blue Cross Blue Shield (BCBS) will be replacing Fallon as the low cost provider.
○ Fallon Select Benchmark plan members will be automatically enrolled in the BCBS Benchmark plan
○ Fallon Select High Deductible plan members will be automatically enrolled in the BCBS High
Deductible plan
○ Fallon Direct Benchmark plan members will be automatically enrolled in the BCBS Benchmark plan.
If members determine that the narrow network (BCBS Select Benchmark) plan fits their needs and
accepts their providers, then they can complete an enrollment form to change to that plan instead.
○ Fallon Direct High Deductible members will be automatically enrolled in the BCBS High Deductible
plan. The Blue Cross narrow network (BCBS Select) high deductible plan network will not be available
until at least 1/1/2023. We will have a separate open enrollment at that time for members who want to
move to the narrow network BCBS high deductible plan.
If you are currently enrolled in a Blue Cross Blue Shield, Harvard Pilgrim or Tufts health plan and not making
any changes during this Open Enrollment- you do not need to do anything. Current Fallon members who wish
to move to a Blue Cross Blue Shield plan other than the one they will be automatically enrolled in or who wish
to change to a Harvard Pilgrim or Tufts plan will have to complete the applicable enrollment form. Further
information regarding this change is enclosed in the attached FY 23 Benefits Change Information document.
This is also the Dental Open Enrollment period, so employees can also elect to make changes or enroll in the
Altus dental plan. Town employees can submit enrollment forms for the dental plan to Nick Hawes and school
employees will receive further information from the School Payroll team regarding their plan’s open enrollment.
Plan information is available on the Town's website: https://shrewsburyma.gov/332/Employee-Benefits.
We will be holding online presentations regarding this Open Enrollment period and the changes for Fallon
members. They will be held at the following times and available via the links below:
March 21st at 6:00pm meet.google.com/nbj-zaef-pvd
March 24th at 1:00pm meet.google.com/ajg-smct-pxe
The presentation will be recorded and posted online for those who cannot make these times.
If you are enrolling in a High Deductible Health Plan (HDHP), a Health Savings Account (HSA) through Health
Equity will be established. Your HSA funds can then be used tax-free to pay for qualified medical expenses. In
addition, your HSA contributions earn tax-free interest and carry over from year-to-year. By selecting an HSA-
qualified plan, you are eligible to contribute tax-free money through payroll deductions into a Health Savings
Account.
The Town will continue to contribute $1,000 for individual plans and $2,000 for family plans annually into the
HSA in two equal installments on or about July 1st and January 1st each year. If you are a Non-Medicare
Retiree and you choose to enroll in a HDHP, your HSA contributions must be directly paid to Health Equity.
Member Services phone numbers and website addresses for the Health Insurance Companies and the HSA
Administrator are listed below.
Insurance Company Customer Service Website
Blue Cross/Blue Shield (800) 782-3675 www.bcbsma.com
Harvard Pilgrim Health Care (888) 333-4742 www.harvardpilgrim.org
Tufts (800) 843-1008 www.tuftshealthplan.com
Health Equity (HSA) (866) 346-5800 www.healthequity.com
Changes to Your Health Insurance
1. If you are: a). a non-Fallon member looking to make a change from your existing coverage to another
plan, b). seeking to enroll or cancel coverage for yourself or any of your dependents, or c). to enroll with
the Town as a new subscriber this year, please complete the insurance application provided on the
Town’s website. If you are enrolling in a HDHP, you must complete an HSA deduction form (even if you
are contributing $0 amount), which is located on the Town’s website.
2. If adding dependents for the first time, you will need to include a copy of their Social Security Card(s),
your city/town issued marriage certificate or divorce decree to include a spouse/ex-spouse, and copies of
birth certificates, adoption forms, guardianship papers etc., to enroll children under age 26.
3. If the change you are making results in a change to the premium, you will pay for the coverage (new,
increase or decrease) and you are required to complete a new Payroll Agreement form, also available on
the Town’s website.
Please Note: decisions made during Open Enrollment are binding for the entire fiscal year and cannot be
changed until next year's Open Enrollment unless you experience a qualifying event that allows for benefit
changes during the year. If this happens, you MUST notify Nick Hawes, Benefits Coordinator, of such a
change within 30 days of the qualifying event date.
All fully completed packets, including applications and accompanying paperwork, must be returned to
Nick Hawes, Benefits Coordinator, in the Town Manager’s Office by 4:30 on Friday, April 15, 2022. These
documents can be dropped off at the Town Manager’s Office or sent in the mail marked to my attention.
Sincerely,
Nick Hawes
Benefits Coordinator
508-841-8318
nhawes@shrewsburyma.gov
Attached: FY23 Benefits Changes Information
FY23 Benefits Changes Information
Effective 6/30/22, Fallon announced they will no longer be providing commercial health insurance coverage.
This means that the Fallon health plans for active employees and non-Medicare eligible retirees will no longer
be offered. This change will occur in coordination with this year's Open Enrollment period for a July 1, 2022
effective date.
How is the Town health coverage changing due to this change?
Participants with an active Fallon plan will be automatically enrolled in the Blue Cross Blue Shield (BCBS) plan
as seen below. Participants can also elect to move to a Harvard Pilgrim or Tufts plan if they prefer those plans.
The most significant change is that these plans have a more limited dental plan, restricted only to children
under the age of 12.
Current Plan New Plan
Fallon Select Benchmark Blue Cross Blue Shield Benchmark
Fallon Direct Benchmark Blue Cross Blue Shield Benchmark
Fallon Select High Deductible Health Plan Blue Cross Blue Shield High Deductible Health Plan
Fallon Direct High Deductible Health Plan Blue Cross Blue Shield High Deductible Health Plan
Blue Cross Blue Shield Plans
Blue Cross Blue Shield will continue to offer their broad network Benchmark and High Deductible plans as in
years past. These plans are comparable to the Fallon Select plans. There are no significant changes to these
plans.
Blue Cross Blue Shield Select Plans
Blue Cross Blue Shield Select is a narrow network plan which will serve in a similar sense that Fallon Direct
did. The network for this plan is different from Fallon Direct, therefore all employees on a Fallon Direct
Benchmark plan will be automatically enrolled in the broad Blue Cross plan with the option to change to the
narrow network once members confirm that their provider is accepted. Moving from the broad Blue Cross
network to the narrow network will require current Fallon Direct Benchmark members to complete an
enrollment form.
The network for the Blue Cross Blue Shield Select High Deductible (HDHP) plan will not be ready for
enrollment until 1/1/2023. All current members will be enrolled in the broad Blue Cross Blue Shield plan. We
will have a separate open enrollment in the fall of 2022 for participants who are interested in enrolling in this
plan.
What do employees need to do?
If an employee plans to move to a Blue Cross Blue Shield plan, they should confirm that their provider is in
their network by going to: Find a Doctor. Blue Cross Blue Shield Benchmark and Blue Cross Blue Shield
HDHP participants can search using the HMO Blue New England network. BCBS Select participants can
search using the HMO Blue Select network.
Employees who are moving from Fallon Select to the corresponding Blue Cross Blue Shield plan do not have
to do anything to make this change. Employees who are moving from Fallon Direct Benchmark plans will be
enrolled in the broad network BCBS plan and can opt to change to the narrow network which would require an
enrollment form. If an employee wishes to change to a Blue Cross Blue Shield plan other than the one they will
be automatically enrolled in, or a Harvard Pilgrim/Tufts plan or terminate their coverage with the town they will
need to complete the applicable form to do so.
Cost Changes
The charts below show the monthly cost change associated with this plan change based on the Town and
School employees whose deductions are over 24 paychecks. School employees who are paid over 21
paychecks, please see the rate charts for your new premium amount.
Benchmark Plans:
Monthly Fallon Select Blue Cross Blue Shield Cost
Cost (FY22) (FY23) Difference
Individual $220.59 $248.64 $28.05
Family $594.00 $669.48 $75.48
Monthly Fallon Direct Blue Cross Blue Shield Select Cost
Cost (FY22) (FY23) Difference
Individual $167.42 $231.56 $64.14
Family $450.34 $623.00 $172.66
High Deductible Health Plans:
Monthly Fallon Select Blue Cross Blue Shield Cost
Cost (FY22) (FY23) Difference
Individual $185.76 $164.56 -$21.20
Family $500.85 $443.52 -$57.33
Monthly Fallon Direct Blue Cross Blue Shield Cost
Cost (FY22) (FY23) Difference
Individual $141.02 $164.56 $23.54
Family $380.60 $443.52 $62.92
TOWN OF SHREWSBURY
WEST SUBURBAN HEALTH GROUP
ACTIVE PLANS 2022-2023
% PAID EMPLOYEE EMP. 24 P/R EMP. 21 P/R
PLAN TYPE
TOWN/EMP MONTHLY BI-WEEKLY BI-WEEKLY*
INDEMNITY PLANS
HARVARD PILGRIM PPO
50/50 FAMILY $3,054.50 $1,527.25 $1,745.43
50/50 INDIVIDUAL $1,375.50 $687.75 $786.00
HIGH DEDUCTIBLE HEALTH PLANS (HDHP)
TUFTS HSA QUALIFED PLAN
63/37 FAMILY $879.49 $439.75 $502.57
63/37 INDIVIDUAL $335.96 $167.98 $191.98
HARVARD PILGRIM HSA QUALIFED PLAN
63/37 FAMILY $828.43 $414.22 $473.39
63/37 INDIVIDUAL $317.46 $158.73 $181.41
BLUE CROSS NETWORK BLUE HSA QUALIFED PLAN
78/22 FAMILY $443.52 $221.76 $253.44
78/22 INDIVIDUAL $164.56 $82.28 $94.03
BENCHMARK HMO PLANS
TUFTS BENCHMARK
60/40 FAMILY $1,228.00 $614.00 $701.71
60/40 INDIVIDUAL $469.20 $234.60 $268.11
HARVARD PILGRIM BENCHMARK
60/40 FAMILY $1,155.20 $577.60 $660.11
60/40 INDIVIDUAL $443.20 $221.60 $253.26
BLUE CROSS NETWORK BLUE BENCHMARK
72/28 FAMILY $669.48 $334.74 $382.56
72/28 INDIVIDUAL $248.64 $124.32 $142.08
BLUE CROSS NETWORK BLUE SELECT BENCHMARK
72/28 FAMILY $623.00 $311.50 $356.00
72/28 INDIVIDUAL $231.56 $115.78 $132.32
*SCHOOL EMPLOYEES PAID ON 21 BI-WEEKLY P/R (SUMMER DEDUCTIONS ARE INCLUDED IN
THE RATES)WEST SUBURBAN HEALTH GROUP
Effective 07-01-2022 HEALTH PLAN COMPARISON CHART - all plans - July 1, 2022
HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Lifetime Benefit Maximum None None None None None None None None None
Deductible - (Benchmark Plans only) None IND $100/ FAM $200 IND $300 IND $2,000 IND $300 IND $300 IND $2,000 IND $300 IND $2,000
applies to: In-patient Admission; Out- FAM $900 FAM $4,000 (Non- FAM $900 FAM $900 FAM $4,000 FAM $900 FAM $4,000
patient Surgery; ER, High Tech Imaging embedded, plan year
(MRI, CT, & PET) and Diagnostic Tests deductible, family plan
& Procedures. Does not apply to office deductible needs to be
visits or pharmacy. Per plan year (July 1 satisfied before
to June 30) - See plan document for full insurance plan kicks in)
details
Out-of-Pocket (OOP) Maximum - Medical - None Medical - Medical & RX Medical - Medical - Medical & RX Medical - Medical & RX
Once your out-of-pocket expenses for $2,000 per member $2,000 per member COMBINED - $2,000 per member $2,000 per member COMBINED - $2,000 per member COMBINED -
applicable services reaches this amount, $4,000 per family per $4,000 per family per $5,000 per member $4,000 per family per $4,000 per family per $5,000 per member $4,000 per family per $5,000 per member
you pay $0 for remainder of plan year. plan year plan year $10,000 per family per plan year plan year $10,000 per family per plan year $10,000 per family
Effective July 1, 2015, out-of-pocket Prescription- $2,000 plan year year Prescription- $2,000 Prescription- $2,000 plan year see Prescription- $2,000 per plan year, see
maximums for prescription copays have per member $4,000 see plan for details per member $4,000 per member $4,000 plan for details per member $4,000 plan for details
been added as required by ACA (in- per family per plan year per family per plan per family per plan per family per plan
network only). see plan for details year see plan year see plan year, see plan for
for details for details details
Family Covered Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents;
and adult children until and adult children until and adult children up to and adult children up to and adult children up to and adult children up to and adult children up to and adult children up to and adult children up
age 26 age 26 age 26 age 26 age 26 age 26 age 26 age 26 to age 26
Selection of Primary Care Physician Any PCP in network No selection required Member must select Member must select Member must select Member must select Member must select No selection required Member must select
(PCP)
Specialist Referrals Any HPHC Specialist Any licensed specialist PCP must refer PCP must refer PCP must refer PCP must refer No referral required No referral required PCP must refer
1HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Providers of Service HARVARD PILGRIM Any licensed provider; HARVARD PILGRIM HARVARD PILGRIM HMO BLUE providers HMO BLUE SELECT HMO BLUE providers in TUFTS HEALTH TUFTS HEALTH
providers - Members any hospital providers except in providers except in in all 6 New England MA PROVIDERS all 6 New England states PLAN providers except PLAN providers
also have access to a emergencies emergencies states except in ONLY except in except in emergencies in emergencies except in emergencies
wide range of emergencies emergencies
participating providers
through the Private
Health Care Systems
network while outside
of MA, NH and ME
A Limited Network with
Great Value HMO
Blue Select features a
smaller and very
attracitve provider
network with
recognized
Massachusetts doctors
and hospitals, as well
as specialty pediatric,
eye, ear, and cancer
hospitals, keeping
employer and
employee affordability
in mind. Hospitals are
aligned with provider
networks to improve
network use.
Pre-existing Conditions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions
INPATIENT
General Hospital/Mental Nothing 20% coinsurance after Deductible applies Deductible, then CIF^ Deductible , then Tier Deductible , then Tier Deductible, then CIF^ Semi-private room & Deductible, then CIF^
Hospital/Substance Abuse Facility deductible then: 1: $500 copay 1: $500 copay board & ancillary
(semi-private room and board and Tier 1 : $250 Tier 2: 1500 copay Tier 2: 1500 copay services
ancillary services) Tier 2 :$500 Tier 1: $500 copay,
Tier 3 : $1500 then deductible applies
per/Admit Tier 2: $1500 copay,
NOTE-Mental then deductible applies
Health/Substance NOTE-Mental
Abuse copay $250 Health/Substance
Abuse copay Tier 1
$500
Physician Services Nothing 20% coinsurance after Nothing Deductible, then CIF^ Nothing Nothing Deductible, then CIF^ Nothing Deductible, then CIF^
deductible
2HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Skilled Nursing Facility Nothing up to 100 days 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible, then Deductible, then Deductible, then CIF^ Covered in Full after Deductible, then CIF^
per calendar year deductible up to 100 then 20% Coinsurance up to 100 days per plan covered in full covered in full Deductible, up to 100 up to 100 days
days per calendar year - Limited to 100 days year days per plan year
per Plan Year
Newborn Well Baby Care (Inpatient) Nothing 20% coinsurance after Nothing Deductible, then CIF^ Nothing Nothing Nothing Nothing Deductible, then CIF^
deductible
OUTPATIENT
Emergency Room Visits for $40 copay, waived if $40 copay, waived if Deductible applies, Deductible, then CIF^ Deductible applies, Deductible applies, Deductible, then CIF^ $100 copay, then Deductible, then CIF^
Emergency or Accident Care admitted admitted then $100 Copay per then $100 Copay per then $100 Copay per deductible applies
visit. Copay is waived if visit. Copay is waived if visit. Copay is waived if (Inpatient copay applies
admitted to the hospital admitted to the hospital admitted to the hospital if admitted)
directly from the directly from the directly from the
emergency room, then emergency room, then emergency room, then
Inpatient copay would Inpatient copay would Inpatient copay would
apply apply apply
Outpatient Surgery in a Day Surgery Nothing 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible applies, Deductible applies, Deductible, then CIF^ $250 copay per Deductible, then CIF^
facility or Hospital deductible then $250 copay per then $250 copay per then $250 copay per outpatient surgery,
visit visit visit then deductible
CT, MRI and Pet Scans Nothing 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible, then $100 Deductible, then $100 Deductible, then CIF^ $100 copay, then Deductible, then CIF^
deductible then $100 Copay per copay (scheduled copay (scheduled Deductible
procedure outpatient) outpatient)
Hemodialysis $5 copayment per visit 20% coinsurance after Non - hospital based - Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible Deductible applies,
then no charge
Hospital based - See
Inpatient Services
3HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Physical Therapy $5 copay per visit 20% coinsurance after Copay: $20 per visit - Deductible, then CIF^ $20 copay; up to 60 $20 copay. PT / OT Deductible, then CIF^ up Speech and short-term Deductible, then CIF^
deductible Limited to 30 visits per Limited to 30 visits per visits per calendar year Max limit up to 60 visits to 60 visits per calendar PT/OT $20 copay per 30 visits per plan year
plan year plan year (unlimited for autism) per plan year year (Unlimited for visit; 30 visits per plan
autism) year
Office Visits Primary Care Physician $5 copay per visit Not covered $20 copay per visit Deductible, then CIF^ $20 copay $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
Preventive OV - PCP Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing
Medical Care/Mental Health $5 copay per visit 20% coinsurance after $20 copay per visit Deductible, then CIF^ $20 per visit $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
Care/Substance Abuse Care (Mental deductible
Health copays excluded from OOP
max)
Office Visits Specialist $5 copay per visit 20% coinsurance after Tier 1 : Deductible, then CIF^ $60 copay per visit $60 copay per visit Deductible, then CIF^ $60 copay per visit Deductible, then CIF^
deductible $30 copay per visit
Tier 2:
$60 copay per visit
Tier 3:
$90 copay per visit
OB/GYN $5 copay per visit 20% coinsurance after $20 copay per visit Deductible, then CIF^ $20 copay per visit $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
deductible
GYN-Preventive Office visit Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing
Diagnostic X-ray and Lab Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Routine Vision Exam $5 copay per visit; one 20% coinsurance after $0 copay - 1 every 2 Deductible, then CIF^ $0 copay; one visit $0 copay per visit; one $0 copay; one visit every $20 copay per visit; Covered in Full-one
visit per calendar year. deductible years every 12 months visit every 12 months 12 months one visit per plan year visit every 12 months
$0 copay for children
under 5 years of age
Eyewear discounts Eyewear discounts Eyewear discounts
available at available at available at
participating providers participating providers participating providers
4HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Pre-Admission Testing - Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Maternity Care visits Nothing 20% coinsurance after Nothing Routine OPD, Pre and Nothing Nothing Nothing for prenatal; all Nothing for prenatal Nothing for prenatal
deductible Post Natal CIF^ other serviceds and postnatal and postnatal
Deductible, then CIF* outpatient care, non outpatient care non
routine deductibe, then routine deductiblel
CIF then CIF
Dental Services Children up to age 14 Children up to age 14 Preventative dental Deductible, then Children under age Children under age Children under age 12: Children under age Children under age
- Covered in full for - 20% coinsurance for children up to age Children up to age 13 - 12: Preventive dental 12: Preventive dental Preventive dental one 12; Preventative dental, 12; Preventative
preventative care. after deductible for 13 - Tier 1 Copayment Preventative dental one exam every six one exam every six exam every six months., periodic oral exam, dental, periodic oral
All members - preventative care. per visit up to two when authorized by months., incl. months., incl. incl. Cleaning, fluoride cleaning, fluoride exam, cleaning,
$5 copay for extraction All members - exams per calendar PCP; Cleaning, fluoride Cleaning, fluoride treatment and x-rays. treatment once every fluoride treatment
of impacted teeth and 20% coinsurance after year, including up to two exams per treatment and x-rays. treatment and x-rays. All members: six months. X-rays: Full once every six
initial emergency deductible for cleaning, fluoride calendar year, including All members: All members: Extraction of impacted mouth once every five months. X-rays: Full
treatment. extraction of impacted treatment and x-rays. cleaning, fluoride Extraction of impacted Extraction of impacted teeth imbedded in the years, bitewing x-rays mouth once every five
teeth and initial Initial emergency treatment and x-rays. teeth imbedded in the teeth imbedded in the bone. Facility charges once every six months, years, bitewing x-rays
emergency treatment. treatment (within 72 Initial emergency bone. Facility charges bone. Facility charges ONLY when a serious and periapicals as once every six
hours of injury) treatment (within 72 ONLY when a serious ONLY when a serious medical condition that needed. MUST use months, and
necessary to repair oral hours of injury) medical condition that medical condition that requires admittance to a participating dentist. periapicals as needed.
injuries. necessary to repair oral requires admittance to requires admittance to network hospital as Emergency Services - MUST use
Extraction of impacted injuries. a network hospital as a network hospital as inpatient in order for LIMITED participating dentist.
teeth. Extraction of impacted inpatient in order for inpatient in order for dental care to be safely TO X RAYS AND Emergency Services -
teeth. dental care to be safely dental care to be safely performed. See EMERGENCY ORAL LIMITED
performed. performed. Outpatient Surgery for SURGERY TO X RAYS AND
benefit information. ER or OFFICE VISIT EMERGENCY ORAL
COPAY SURGERY
WILL APPLY ER or OFFICE VISIT
COPAY
WILL APPLY
OTHER FEATURES
Private Duty Nursing Nothing when 20% coinsurance after Nothing when Deductible, then CIF^ Nothing when Nothing when Deductible, then CIF^
Not a covered benefit Not a covered benefit
medically necessary deductible medically necessary medically necessary medically necessary
(only when medically necessary)
Home Health Care Nothing 20% coinsurance after Member cost sharing Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible depends on types of
services provided and
tier placement of
provider rendering
dervices, as listed in
the Schedule of
Benefits
5HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Hospice Care Nothing 20% coinsurance after Same as Home Health Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible Care
Durable Medical Equipment 20% of equipment Deductible, then 20% Deductible, then CIF^ Deductible, then CIF^ Deductible, then 20% Deductible, then 20% Deductible, then CIF^ Covered in Full Deductible, then CIF^
cost to HPHC not to of equipment cost to coinsurance coinsurance
exceed a member's HPHC not to exceed a
expense of $1000, member's expense of
$1000
Ambulance Nothing, when Nothing, when T1 deductible, then CIF Deductible, then CIF^ Deductible then Deductible then Deductible, then CIF^ Covered in full when Deductible, then CIF^
medically necessary medically necessary covered in full covered in full medically nceessary
Radiation Therapy Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Chemotherapy Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Chiropractor Visits $5 copay per visit, up 20% coinsurance after $20 copay, 20 visits Deductible, then CIF^ $20 copay per visit. $20 copay per visit; up Deductible, then CIF^ 12 $20 copay per visit; up Deductible, then CIF^
to $500 per calendar deductible per plan year 12 visits per plan year 12 visits maximum per to 12 visits per plan visits per calendar year to 12 visits per 12 visits per plan year
year calendar year year. calendar year
Acupuncture Visits $5 Copayment per visit Deductible, then 20% $30 copay. 12 visits Deductible, then CIF 12 $60 Copay, 12 visits $60 Copay, 12 visits Deductible, then CIF, 12 $20 Copay, unlimited Deductible then CIF,
(12 visits per clendar per plan year visits per plan year per calendar year per calendar year visits per calendar year visits unlimited visits
year)
Prescription Drugs Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy:
Copays AFTER Copays AFTER Copays AFTER
DEDUCTIBLE DEDUCTIBLE DEDUCTIBLE
(Inpatient drugs paid in full) Tier 1: $5 copay Tier 1: $5 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay
Tier 2: $10 copay Tier 2: $10 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay
Tier 3: $25 copay Tier 3: $25 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay
up to a 30 day supply up to a 30 day supply (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply)
MedImpact Mail No mail order Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day
Order: coverage except supply) supply) Copays supply) supply) supply) Copays supply) supply) Copays
through AFTER DEDUCTIBLE AFTER DEDUCTIBLE AFTER
DEDUCTIBLE
Tier 1: $10 copay MedImpact Mail Order Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay
Tier 2: $20 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay
Tier 3: $75 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay
up to a 90 day supply
6HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Fitness Benefit Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement
Fitness reimb up to Fitness reimb up to Fitness reimb up to Fitness reimb up to Up to $300 Up to $300 Up to $300 Fitness reimb up to Fitness reimb up to
$150 per subscriber at $150 per subscriber at $150 per subscriber at $150 per subscriber at a reimbursement toward reimbursement toward reimbursement toward $150 per subscriber at $150 per subscriber
a Health & Fitness club a Health & Fitness club a Health & Fitness club Health & Fitness club health club health club health club membership a Health & Fitness at a Health & Fitness
per calendar year. per calendar year. per calendar year. per calendar year. Must membership and membership and and classes and/or club,including exercise club,including
Must be an active Must be an active Must be an active be an active member of classes and/or virtual classes and/or virtual virtual memberships and classes per calendar exercise classes per
member of HPHC for member of HPHC for member of HPHC for HPHC for at least 4 memberships and memberships and classes. See plan year. See plan calendar year. See
at least 4 months and at least 4 months and at least 4 months and months and an active classes. See plan classes. See plan materials for details. materials for details. plan materials for
an active member of an active member of an active member of member of the health materials for details. materials for details. details.
the health facility for at the health facility for at the health facility for at facility for at least 4
least 4 months. least 4 months. least 4 months. months.
See plan materials for See plan materials for See plan materials for See plan materials for
details. details. details. details.
Discounts at IFCN- Discounts at IFCN- Discounts at IFCN- Discounts at IFCN- Enroll in a qualified Enroll in a qualified Enroll in a qualified JENNY CRAIG JENNY CRAIG
affiliated clubs. affiliated clubs. affiliated clubs. affiliated clubs. Weight Watchers® or Weight Watchers® or Weight Watchers® or DISCOUNTS: DISCOUNTS:
Discount at Weight Discount at Weight Discount at Weight Discount at Weight hospital based weight hospital based weight hospital based weight -FREE 30 DAY -FREE 30 DAY
Watchers® Watchers® Watchers® Watchers® loss program and loss program and loss program and PROGRAM PROGRAM
receive up to $150 per receive up to $150 per receive up to $150 per -25% OFF A -25% OFF A
calendar year toward calendar year toward calendar year toward PREMIUM/METABOLI PREMIUM/METABOL
your program fees. your program fees. your program fees. C PROGRAM IC PROGRAM
NUTRISYSTEM NUTRISYSTEM
DISCOUNT: DISCOUNT:
-12% DISCOUNT - -12% DISCOUNT -
OFF CURRENT OFF CURRENT
PROMO PROMO
-CORE OR SELECT -CORE OR SELECT
PROGRAM PROGRAM
8WEST SUBURBAN HEALTH GROUP
Effective 07-01-2022 HEALTH PLAN COMPARISON CHART - all plans - July 1, 2022
HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Lifetime Benefit Maximum None None None None None None None None None
Deductible - (Benchmark Plans only) None IND $100/ FAM $200 IND $300 IND $2,000 IND $300 IND $300 IND $2,000 IND $300 IND $2,000
applies to: In-patient Admission; Out- FAM $900 FAM $4,000 (Non- FAM $900 FAM $900 FAM $4,000 FAM $900 FAM $4,000
patient Surgery; ER, High Tech Imaging embedded, plan year
(MRI, CT, & PET) and Diagnostic Tests deductible, family plan
& Procedures. Does not apply to office deductible needs to be
visits or pharmacy. Per plan year (July 1 satisfied before
to June 30) - See plan document for full insurance plan kicks in)
details
Out-of-Pocket (OOP) Maximum - Medical - None Medical - Medical & RX Medical - Medical - Medical & RX Medical - Medical & RX
Once your out-of-pocket expenses for $2,000 per member $2,000 per member COMBINED - $2,000 per member $2,000 per member COMBINED - $2,000 per member COMBINED -
applicable services reaches this amount, $4,000 per family per $4,000 per family per $5,000 per member $4,000 per family per $4,000 per family per $5,000 per member $4,000 per family per $5,000 per member
you pay $0 for remainder of plan year. plan year plan year $10,000 per family per plan year plan year $10,000 per family per plan year $10,000 per family
Effective July 1, 2015, out-of-pocket Prescription- $2,000 plan year year Prescription- $2,000 Prescription- $2,000 plan year see Prescription- $2,000 per plan year, see
maximums for prescription copays have per member $4,000 see plan for details per member $4,000 per member $4,000 plan for details per member $4,000 plan for details
been added as required by ACA (in- per family per plan year per family per plan per family per plan per family per plan
network only). see plan for details year see plan year see plan year, see plan for
for details for details details
Family Covered Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents; Spouse; dependents;
and adult children until and adult children until and adult children up to and adult children up to and adult children up to and adult children up to and adult children up to and adult children up to and adult children up
age 26 age 26 age 26 age 26 age 26 age 26 age 26 age 26 to age 26
Selection of Primary Care Physician Any PCP in network No selection required Member must select Member must select Member must select Member must select Member must select No selection required Member must select
(PCP)
Specialist Referrals Any HPHC Specialist Any licensed specialist PCP must refer PCP must refer PCP must refer PCP must refer No referral required No referral required PCP must refer
1HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Providers of Service HARVARD PILGRIM Any licensed provider; HARVARD PILGRIM HARVARD PILGRIM HMO BLUE providers HMO BLUE SELECT HMO BLUE providers in TUFTS HEALTH TUFTS HEALTH
providers - Members any hospital providers except in providers except in in all 6 New England MA PROVIDERS all 6 New England states PLAN providers except PLAN providers
also have access to a emergencies emergencies states except in ONLY except in except in emergencies in emergencies except in emergencies
wide range of emergencies emergencies
participating providers
through the Private
Health Care Systems
network while outside
of MA, NH and ME
A Limited Network with
Great Value HMO
Blue Select features a
smaller and very
attracitve provider
network with
recognized
Massachusetts doctors
and hospitals, as well
as specialty pediatric,
eye, ear, and cancer
hospitals, keeping
employer and
employee affordability
in mind. Hospitals are
aligned with provider
networks to improve
network use.
Pre-existing Conditions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions
INPATIENT
General Hospital/Mental Nothing 20% coinsurance after Deductible applies Deductible, then CIF^ Deductible , then Tier Deductible , then Tier Deductible, then CIF^ Semi-private room & Deductible, then CIF^
Hospital/Substance Abuse Facility deductible then: 1: $500 copay 1: $500 copay board & ancillary
(semi-private room and board and Tier 1 : $250 Tier 2: 1500 copay Tier 2: 1500 copay services
ancillary services) Tier 2 :$500 Tier 1: $500 copay,
Tier 3 : $1500 then deductible applies
per/Admit Tier 2: $1500 copay,
NOTE-Mental then deductible applies
Health/Substance NOTE-Mental
Abuse copay $250 Health/Substance
Abuse copay Tier 1
$500
Physician Services Nothing 20% coinsurance after Nothing Deductible, then CIF^ Nothing Nothing Deductible, then CIF^ Nothing Deductible, then CIF^
deductible
2HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Skilled Nursing Facility Nothing up to 100 days 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible, then Deductible, then Deductible, then CIF^ Covered in Full after Deductible, then CIF^
per calendar year deductible up to 100 then 20% Coinsurance up to 100 days per plan covered in full covered in full Deductible, up to 100 up to 100 days
days per calendar year - Limited to 100 days year days per plan year
per Plan Year
Newborn Well Baby Care (Inpatient) Nothing 20% coinsurance after Nothing Deductible, then CIF^ Nothing Nothing Nothing Nothing Deductible, then CIF^
deductible
OUTPATIENT
Emergency Room Visits for $40 copay, waived if $40 copay, waived if Deductible applies, Deductible, then CIF^ Deductible applies, Deductible applies, Deductible, then CIF^ $100 copay, then Deductible, then CIF^
Emergency or Accident Care admitted admitted then $100 Copay per then $100 Copay per then $100 Copay per deductible applies
visit. Copay is waived if visit. Copay is waived if visit. Copay is waived if (Inpatient copay applies
admitted to the hospital admitted to the hospital admitted to the hospital if admitted)
directly from the directly from the directly from the
emergency room, then emergency room, then emergency room, then
Inpatient copay would Inpatient copay would Inpatient copay would
apply apply apply
Outpatient Surgery in a Day Surgery Nothing 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible applies, Deductible applies, Deductible, then CIF^ $250 copay per Deductible, then CIF^
facility or Hospital deductible then $250 copay per then $250 copay per then $250 copay per outpatient surgery,
visit visit visit then deductible
CT, MRI and Pet Scans Nothing 20% coinsurance after Deductible applies, Deductible, then CIF^ Deductible, then $100 Deductible, then $100 Deductible, then CIF^ $100 copay, then Deductible, then CIF^
deductible then $100 Copay per copay (scheduled copay (scheduled Deductible
procedure outpatient) outpatient)
Hemodialysis $5 copayment per visit 20% coinsurance after Non - hospital based - Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible Deductible applies,
then no charge
Hospital based - See
Inpatient Services
3HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Physical Therapy $5 copay per visit 20% coinsurance after Copay: $20 per visit - Deductible, then CIF^ $20 copay; up to 60 $20 copay. PT / OT Deductible, then CIF^ up Speech and short-term Deductible, then CIF^
deductible Limited to 30 visits per Limited to 30 visits per visits per calendar year Max limit up to 60 visits to 60 visits per calendar PT/OT $20 copay per 30 visits per plan year
plan year plan year (unlimited for autism) per plan year year (Unlimited for visit; 30 visits per plan
autism) year
Office Visits Primary Care Physician $5 copay per visit Not covered $20 copay per visit Deductible, then CIF^ $20 copay $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
Preventive OV - PCP Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing
Medical Care/Mental Health $5 copay per visit 20% coinsurance after $20 copay per visit Deductible, then CIF^ $20 per visit $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
Care/Substance Abuse Care (Mental deductible
Health copays excluded from OOP
max)
Office Visits Specialist $5 copay per visit 20% coinsurance after Tier 1 : Deductible, then CIF^ $60 copay per visit $60 copay per visit Deductible, then CIF^ $60 copay per visit Deductible, then CIF^
deductible $30 copay per visit
Tier 2:
$60 copay per visit
Tier 3:
$90 copay per visit
OB/GYN $5 copay per visit 20% coinsurance after $20 copay per visit Deductible, then CIF^ $20 copay per visit $20 copay per visit Deductible, then CIF^ $20 copay per visit Deductible, then CIF^
deductible
GYN-Preventive Office visit Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing Nothing
Diagnostic X-ray and Lab Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Routine Vision Exam $5 copay per visit; one 20% coinsurance after $0 copay - 1 every 2 Deductible, then CIF^ $0 copay; one visit $0 copay per visit; one $0 copay; one visit every $20 copay per visit; Covered in Full-one
visit per calendar year. deductible years every 12 months visit every 12 months 12 months one visit per plan year visit every 12 months
$0 copay for children
under 5 years of age
Eyewear discounts Eyewear discounts Eyewear discounts
available at available at available at
participating providers participating providers participating providers
4HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Pre-Admission Testing - Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Maternity Care visits Nothing 20% coinsurance after Nothing Routine OPD, Pre and Nothing Nothing Nothing for prenatal; all Nothing for prenatal Nothing for prenatal
deductible Post Natal CIF^ other serviceds and postnatal and postnatal
Deductible, then CIF* outpatient care, non outpatient care non
routine deductibe, then routine deductiblel
CIF then CIF
Dental Services Children up to age 14 Children up to age 14 Preventative dental Deductible, then Children under age Children under age Children under age 12: Children under age Children under age
- Covered in full for - 20% coinsurance for children up to age Children up to age 13 - 12: Preventive dental 12: Preventive dental Preventive dental one 12; Preventative dental, 12; Preventative
preventative care. after deductible for 13 - Tier 1 Copayment Preventative dental one exam every six one exam every six exam every six months., periodic oral exam, dental, periodic oral
All members - preventative care. per visit up to two when authorized by months., incl. months., incl. incl. Cleaning, fluoride cleaning, fluoride exam, cleaning,
$5 copay for extraction All members - exams per calendar PCP; Cleaning, fluoride Cleaning, fluoride treatment and x-rays. treatment once every fluoride treatment
of impacted teeth and 20% coinsurance after year, including up to two exams per treatment and x-rays. treatment and x-rays. All members: six months. X-rays: Full once every six
initial emergency deductible for cleaning, fluoride calendar year, including All members: All members: Extraction of impacted mouth once every five months. X-rays: Full
treatment. extraction of impacted treatment and x-rays. cleaning, fluoride Extraction of impacted Extraction of impacted teeth imbedded in the years, bitewing x-rays mouth once every five
teeth and initial Initial emergency treatment and x-rays. teeth imbedded in the teeth imbedded in the bone. Facility charges once every six months, years, bitewing x-rays
emergency treatment. treatment (within 72 Initial emergency bone. Facility charges bone. Facility charges ONLY when a serious and periapicals as once every six
hours of injury) treatment (within 72 ONLY when a serious ONLY when a serious medical condition that needed. MUST use months, and
necessary to repair oral hours of injury) medical condition that medical condition that requires admittance to a participating dentist. periapicals as needed.
injuries. necessary to repair oral requires admittance to requires admittance to network hospital as Emergency Services - MUST use
Extraction of impacted injuries. a network hospital as a network hospital as inpatient in order for LIMITED participating dentist.
teeth. Extraction of impacted inpatient in order for inpatient in order for dental care to be safely TO X RAYS AND Emergency Services -
teeth. dental care to be safely dental care to be safely performed. See EMERGENCY ORAL LIMITED
performed. performed. Outpatient Surgery for SURGERY TO X RAYS AND
benefit information. ER or OFFICE VISIT EMERGENCY ORAL
COPAY SURGERY
WILL APPLY ER or OFFICE VISIT
COPAY
WILL APPLY
OTHER FEATURES
Private Duty Nursing Nothing when 20% coinsurance after Nothing when Deductible, then CIF^ Nothing when Nothing when Deductible, then CIF^
Not a covered benefit Not a covered benefit
medically necessary deductible medically necessary medically necessary medically necessary
(only when medically necessary)
Home Health Care Nothing 20% coinsurance after Member cost sharing Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible depends on types of
services provided and
tier placement of
provider rendering
dervices, as listed in
the Schedule of
Benefits
5HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Hospice Care Nothing 20% coinsurance after Same as Home Health Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible Care
Durable Medical Equipment 20% of equipment Deductible, then 20% Deductible, then CIF^ Deductible, then CIF^ Deductible, then 20% Deductible, then 20% Deductible, then CIF^ Covered in Full Deductible, then CIF^
cost to HPHC not to of equipment cost to coinsurance coinsurance
exceed a member's HPHC not to exceed a
expense of $1000, member's expense of
$1000
Ambulance Nothing, when Nothing, when T1 deductible, then CIF Deductible, then CIF^ Deductible then Deductible then Deductible, then CIF^ Covered in full when Deductible, then CIF^
medically necessary medically necessary covered in full covered in full medically nceessary
Radiation Therapy Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Chemotherapy Nothing 20% coinsurance after Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^ Deductible, then CIF^
deductible
Chiropractor Visits $5 copay per visit, up 20% coinsurance after $20 copay, 20 visits Deductible, then CIF^ $20 copay per visit. $20 copay per visit; up Deductible, then CIF^ 12 $20 copay per visit; up Deductible, then CIF^
to $500 per calendar deductible per plan year 12 visits per plan year 12 visits maximum per to 12 visits per plan visits per calendar year to 12 visits per 12 visits per plan year
year calendar year year. calendar year
Acupuncture Visits $5 Copayment per visit Deductible, then 20% $30 copay. 12 visits Deductible, then CIF 12 $60 Copay, 12 visits $60 Copay, 12 visits Deductible, then CIF, 12 $20 Copay, unlimited Deductible then CIF,
(12 visits per clendar per plan year visits per plan year per calendar year per calendar year visits per calendar year visits unlimited visits
year)
Prescription Drugs Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy:
Copays AFTER Copays AFTER Copays AFTER
DEDUCTIBLE DEDUCTIBLE DEDUCTIBLE
(Inpatient drugs paid in full) Tier 1: $5 copay Tier 1: $5 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay
Tier 2: $10 copay Tier 2: $10 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay
Tier 3: $25 copay Tier 3: $25 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay
up to a 30 day supply up to a 30 day supply (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply)
MedImpact Mail No mail order Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day
Order: coverage except supply) supply) Copays supply) supply) supply) Copays supply) supply) Copays
through AFTER DEDUCTIBLE AFTER DEDUCTIBLE AFTER
DEDUCTIBLE
Tier 1: $10 copay MedImpact Mail Order Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay
Tier 2: $20 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay
Tier 3: $75 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay
up to a 90 day supply
6HARVARD PILGRIM HEALTH CARE BLUE CROSS BLUE SHIELD TUFTS HEALTH PLAN
PLAN TYPE PPO BENCHMARK HIGH DEDUCTIBLE BENCHMARK BENCHMARK HIGH DEDUCTIBLE BENCHMARK HIGH DEDUCTIBLE
^ CIF = Covered in Full IN-NETWORK OUT-OF-NETWORK CHOICENET HSA ELIGIBLE NETWORK BLUE NE
NETWORK BLUE
HSA ELIGIBLE HSA ELIGIBLE
SELECT
BENEFIT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY
Fitness Benefit Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement
Fitness reimb up to Fitness reimb up to Fitness reimb up to Fitness reimb up to Up to $300 Up to $300 Up to $300 Fitness reimb up to Fitness reimb up to
$150 per subscriber at $150 per subscriber at $150 per subscriber at $150 per subscriber at a reimbursement toward reimbursement toward reimbursement toward $150 per subscriber at $150 per subscriber
a Health & Fitness club a Health & Fitness club a Health & Fitness club Health & Fitness club health club health club health club membership a Health & Fitness at a Health & Fitness
per calendar year. per calendar year. per calendar year. per calendar year. Must membership and membership and and classes and/or club,including exercise club,including
Must be an active Must be an active Must be an active be an active member of classes and/or virtual classes and/or virtual virtual memberships and classes per calendar exercise classes per
member of HPHC for member of HPHC for member of HPHC for HPHC for at least 4 memberships and memberships and classes. See plan year. See plan calendar year. See
at least 4 months and at least 4 months and at least 4 months and months and an active classes. See plan classes. See plan materials for details. materials for details. plan materials for
an active member of an active member of an active member of member of the health materials for details. materials for details. details.
the health facility for at the health facility for at the health facility for at facility for at least 4
least 4 months. least 4 months. least 4 months. months.
See plan materials for See plan materials for See plan materials for See plan materials for
details. details. details. details.
Discounts at IFCN- Discounts at IFCN- Discounts at IFCN- Discounts at IFCN- Enroll in a qualified Enroll in a qualified Enroll in a qualified JENNY CRAIG JENNY CRAIG
affiliated clubs. affiliated clubs. affiliated clubs. affiliated clubs. Weight Watchers® or Weight Watchers® or Weight Watchers® or DISCOUNTS: DISCOUNTS:
Discount at Weight Discount at Weight Discount at Weight Discount at Weight hospital based weight hospital based weight hospital based weight -FREE 30 DAY -FREE 30 DAY
Watchers® Watchers® Watchers® Watchers® loss program and loss program and loss program and PROGRAM PROGRAM
receive up to $150 per receive up to $150 per receive up to $150 per -25% OFF A -25% OFF A
calendar year toward calendar year toward calendar year toward PREMIUM/METABOLI PREMIUM/METABOL
your program fees. your program fees. your program fees. C PROGRAM IC PROGRAM
NUTRISYSTEM NUTRISYSTEM
DISCOUNT: DISCOUNT:
-12% DISCOUNT - -12% DISCOUNT -
OFF CURRENT OFF CURRENT
PROMO PROMO
-CORE OR SELECT -CORE OR SELECT
PROGRAM PROGRAM
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