SUMMARY OF BENEFITS

Preferred Blue PPO

® Wistia

$3,000 Deductible
Plan-Year Deductible: $3,000/$6,000

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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 Choice
Your Deductible Telehealth Services
Your deductible is the amount of money you pay out-of-pocket each plan Telehealth services are covered when the same in-person service would be
year before you can receive coverage for certain benefits under this plan. If covered by the health plan and the use of telehealth is appropriate. Your health
you are not sure when your plan year begins, contact Blue Cross Blue Shield care provider will work with you to determine if a telehealth visit is medically
of Massachusetts. Your deductible is $3,000 per member (or $6,000 per family) appropriate for your health care needs or if an in-person visit is required. For a list
for in-network and out-of-network services combined. of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website
at bluecrossma.org, consult Find a Doctor, or call the Member Service number
When You Choose Preferred Providers on your ID card.
You receive the highest level of benefits under your health care plan when
you obtain covered services from preferred providers. These are called your Your Virtual Care Team
“in-network” benefits. See the charts for your cost share. Your health plan includes an option for a tech-enabled primary care delivery
model where virtual care team covered providers furnish certain covered
Note: If a preferred provider refers you to another provider for covered services (such as a lab
or specialist), make sure the provider is a preferred provider in order to receive benefits at the services. See your subscriber certificate (and riders, if any) for exact
in-network level. If the provider you use is not a preferred provider, you’re still covered, but your coverage details.
benefits, in most situations, will be covered at the out-of-network level, even if the preferred
provider refers you.
Utilization Review Requirements
How to Find a Preferred Provider Certain services require pre-approval/prior authorization through Blue Cross
To find a preferred provider: Blue Shield of Massachusetts for you to have benefit coverage; this includes
non-emergency and non-maternity hospitalization and may include certain
• Look up a provider on Find a Doctor at bluecrossma.com/findadoctor. If you
outpatient services, therapies, procedures, and drugs. You should work with your
need a copy of your directory or help choosing a provider, call the Member
health care provider to determine if pre-approval is required for any service
Service number on your ID card.
your provider is suggesting. If your provider, or you, don’t get pre-approval when
• Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org it’s required, your benefits will be denied, and you may be fully responsible for
payment to the provider of the service. Refer to your subscriber certificate for
When You Choose Non-Preferred Providers requirements and the process you should follow for Utilization Review, including
You can also obtain covered services from non-preferred providers, but your Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge
out-of-pocket costs are higher. These are called your “out-of-network” benefits. Planning, and Individual Case Management.
See the charts for your cost share.
Dependent Benefits
Payments for out-of-network benefits are based on the Blue Cross Blue Shield This plan covers dependents until the end of the calendar month in which
allowed charge as defined in your subscriber certificate. You may be responsible they turn age 26, regardless of their financial dependency, student status, or
for any difference between the allowed charge and the provider’s actual billed employment status. See your subscriber certificate (and riders, if any) for exact
charge (this is in addition to your deductible and/or your coinsurance). coverage details.

Your Out-of-Pocket Maximum Domestic Partner Coverage

Your out-of-pocket maximum is the most that you could pay during a plan Domestic partner coverage may be available for eligible dependents. Contact
year for deductible, copayments, and coinsurance for covered services. your plan sponsor for more information.
Your out-of-pocket maximum for medical benefits is $5,450 per member
(or $10,900 per family) for in-network and out-of-network services combined.
Your out-of-pocket maximum for prescription drug benefits is $1,000 per
member (or $2,000 per family) for in-network and out-of-network combined.

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). After meeting your deductible, you pay a copayment
per visit for in-network or out-of-network emergency room services. The
copayment is waived if you are admitted to the hospital or for an observation
stay. See the chart for your cost share.
Covered Services Your Cost In-Network Your Cost Out-of-Network

Preventive Care
Well-child care exams, including routine tests, according to age-based schedule as follows: Nothing, no deductible 20% coinsurance after deductible
• Ten visits during the first year of life
• Three visits during the second year of life (age 1 to age 2)
• Two visits for age 2
• One visit per calendar year for age 3 and older
Routine adult physical exams, including related tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible
Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible
Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible
Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the 20% coinsurance after deductible
maximum, no deductible and all charges beyond the
maximum
Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible
Family planning services—office visits Nothing, no deductible 20% coinsurance after deductible

Outpatient Care
Emergency room visits $250 per visit after deductible $250 per visit after deductible
(copayment waived if admitted (copayment waived if admitted
or for an observation stay) or for an observation stay)

Office or health center visits $25 per visit, no deductible 20% coinsurance after deductible
Mental health or substance use treatment $25 per visit, no deductible 20% coinsurance after deductible
Outpatient telehealth services
• With a covered provider Same as in-person visit Same as in-person visit
• With the in-network designated telehealth vendor $25 per visit, no deductible Only applicable in-network
Diabetic management services (first two visits per calendar year*) Nothing, no deductible 20% coinsurance after deductible
Chiropractors’ office visits $25 per visit, no deductible 20% coinsurance after deductible
Acupuncture visits (up to 12 visits per calendar year) $25 per visit, no deductible 20% coinsurance after deductible
Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year**) $25 per visit, no deductible 20% coinsurance after deductible
Speech, hearing, and language disorder treatment—speech therapy $25 per visit, no deductible 20% coinsurance after deductible
Diagnostic X-rays and lab tests, including CT scans, MRIs, PET scans, Nothing after deductible 20% coinsurance after deductible
and nuclear cardiac imaging tests
Home health care and hospice services Nothing after deductible 20% coinsurance after deductible
Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible
Durable medical equipment—such as wheelchairs, crutches, hospital beds 20% coinsurance after 40% coinsurance after
deductible*** deductible***

Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible
Surgery and related anesthesia
• Office or health center services $25 per visit†, no deductible 20% coinsurance after deductible
• Ambulatory surgical facility, hospital outpatient department, or surgical day care unit Nothing after deductible 20% coinsurance after deductible

Inpatient Care (including maternity care)

General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible
Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible
Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible
Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible
* These diabetic services are for diabetes evaluation and management services, diabetic eye exams, or diabetic foot care.
** 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.
*** In-network cost share waived for one breast pump per birth, including supplies (20% coinsurance after deductible out-of-network).
† 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.
 Covered Services Your Cost In-Network Your Cost Out-of-Network

Prescription Drug Benefits*

At designated retail pharmacies No deductible No deductible
(up to a 30-day formulary supply for each prescription or refill)** $15 for Tier 1 $30 for Tier 1
$30 for Tier 2 $60 for Tier 2
$50 for Tier 3 $100 for Tier 3
Through the designated mail service pharmacy No deductible Not covered
(up to a 90-day formulary supply for each prescription or refill)** $30 for Tier 1
$60 for Tier 2
$150 for Tier 3
* Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs.
** Cost share may be waived or reduced for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share.

Get the Most from Your Plan: Visit us at bluecrossma.org or call 1-800-782-3675 to learn about discounts, savings, resources, and special programs
available to you, like those listed below.

Wellness Participation Program

Fitness Reimbursement: a program that rewards participation in qualified fitness $150 per calendar year per policy
programs or equipment (See your subscriber certificate for details.)
Weight Loss Reimbursement: a program that rewards participation in a qualified $150 per calendar year per policy
weight loss program (See your subscriber certificate for details.)

24/7 Nurse Line: Speak to a registered nurse, day or night, to get immediate guidance and advice. Call 1-888-247-BLUE (2583). No additional charge.

Questions?
For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675,
or visit us online at bluecrossma.org.

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. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
Printed at Blue Cross and Blue Shield of Massachusetts, Inc.
002770023 (3/24) GSP
 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.

If you believe that Blue Cross Blue Shield

of Massachusetts has failed to provide
Blue Cross Blue Shield these services or discriminated in another
way on the basis of race, color, national
of Massachusetts provides: origin, age, disability, sex, sexual orientation,
or gender identity, you can file a grievance
• Free aids and services to people with with the Civil Rights Coordinator by mail
disabilities to communicate effectively at Civil Rights Coordinator, Blue Cross
with us, such as qualified sign language Blue Shield of Massachusetts,
interpreters and written information in other One Enterprise Drive, Quincy, MA 02171-2126;
formats (large print or other formats). phone at 1-800-472-2689 (TTY: 711);
fax at 1-617-246-3616; or email at
• Free language services to people whose [email protected].
primary language is not English, such as
qualified interpreters and information written If you need help filing a grievance, the Civil
in other languages. Rights Coordinator is available to help you.

If you need these services, call Member Service You can also file a civil rights complaint
at the number on your ID card. 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 1-800-368-1019 or 1-800-537-7697 (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.
© 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
001651238 55-1487 (3/24)
 Translation Resources
TRANSLATION RESOURCES
Proficiency of Language Assistance Services

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 (TTY: 711).
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 (TTY: 711).
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 (TTY: 711).
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).
Arabic/‫ةيرب‬:
‫ اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات املساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النيص للصم والبكم‬

Mon-Khmer, Cambodian/ខ្មែរ: ការជូនដំណឹង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ

បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណ្ណសរាគាេ់្ួនរ្រស់
លៃ អ្នក (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
(TTY: 711).
Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.
Greek/Eλληνικά:
Greek/λληνικά: ΠΡΟΣΟΧΗ:
ΠΡΟΣΟΧΗ:Εάν
Εάνμιλάτε
μιλάτεΕλληνικά,
Ελληνικά,διατίθενται
διατίθενταιγιαγιασας
σαςυπηρεσίες
υπηρεσίεςγλωσσικής
γλωσσικήςβοήθειας,
βοήθειας,
δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card)
(TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

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
(TTY: 711).
Hindi/हिंदी: ध्यान दें : ्दद आप दिनददी बोलते िैं, तो भयाषया सिया्तया सेवयाएँ, आप के ललए नन:शुलक
उपलब्ध िैं। सदस् सेवयाओं को आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल करें (टदी.टदी.वयाई.: 711).
Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે .
તમયારયા આઈડી કયાડ્ડ પર આપેલયા નંબર પર Member Service ને કૉલ કરો (TTY: 711).
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 (TTY: 711).
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
(TTY: 711).
Persian/‫پارسیان‬:
‫ با شمار تلفن مندرج بر روی کارت شناسایی‬.‫ خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد‬،‫ اگر زبان شما فارسی است‬:‫توج‬
.(TTY: 711) ‫خود با بخش «خدمات اعضا» تماس بگیر ید‬
Lao/ພາສາລາວ: ໍຂ ້ ຄວນໃສ ່ ໃຈ: ຖ
້ າເຈົ ້ າເວ
ົ ້ າພາສາລາວໄດ ້ , ີມການບ ໍ ິ ລການຊ ່ ວຍເຫື ຼ ອດ້ ານພາສາໃຫ້ ທ
່ ານໂດຍ
່ໍບເສຍຄ ່ າ. ໂທ ຫາ ຝ
່ າຍບ
ໍ ິ ລການສະ ມາ ຊກທ
ິ ີ ່ ໝາຍເລກໂທລະສ ບຢ
ັ ູ່ ໃນບ ັ ດຂອງທ ່ ານ (TTY: 711).
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 (TTY: 711).

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. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
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.
164711MB 55-1493 (8/16)
© 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
001651831 55-1493 (6/23)