Your Care Access Emergency Room Services This plan gives you the option to go directly to a specialist or any doctor in the In an emergency, such as a suspected heart attack, stroke, or poisoning, HMO Blue New England network without a referral. Just show your Blue Cross you should go directly to the nearest medical f acility or call 911 (or the local Blue Shield of Massachusetts ID card and receive care. However, some services emergency phone number). After meeting your deductible, you pay a copayment do require authorization. See your subscriber certi昀椀cate for details. per visit for emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your Primary Care Provider (PCP) cost share. When you enroll in this health plan, you must choose a primary care provider. Be sure to select a doctor who is accepting you and your family members as new Telehealth Services patients and participates in our network of providers in New England. For children, Telehealth services are covered when the same in-person service would be you may designate a participating network pediatrician as the PCP. covered by the health plan and the use of telehealth is appropriate. Your health care provider will work with you to determine if a telehealth visit is medically For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross appropriate for your health care needs or if an in-person visit is required. For a list Blue Shield of Massachusetts website at bluecrossma.org; consult Find a Doctor of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.com/昀椀ndadoctor; or call the Member Service number on your at bluecrossma.org, consult Find a Doctor, or call the Member Service number ID card. on your ID card. If you have trouble choosing a doctor, Member Service can help. They can give Your Virtual Care Team you the doctor’s gender, the medical school the doctor attended, and whether Your health plan includes an option for a tech-enabled primary care delivery there are languages other than English spoken in the of昀椀ce. model where virtual care team covered providers furnish certain covered services. See your subscriber certi昀椀cate (and riders, if any) for exact Your provider may also work with Blue Cross Blue Shield of Massachusetts coverage details. regarding Utilization Review Requirements, including Pre-Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Service Area Services, and Individual Case Management. For detailed information about The plan’s service area includes all cities and towns in the Commonwealth of Utilization Review, see your subscriber certi昀椀cate. Massachusetts, State of Rhode Island, State of Vermont, State of Connecticut, State of New Hampshire, and State of Maine. Your Deductible Your deductible is the amount of money you pay out-of-pocket When Outside the Service Area each plan year before you can receive coverage for certain bene昀椀ts under If you’re traveling outside the service area and you need urgent or emergency this plan. If you are not sure when your plan year begins, contact Blue Cross care, you should go to the nearest appropriate health care facility. You are Blue Shield of Massachusetts. Your deductible is $4,500 per member covered for the urgent or emergency care visit and one follow-up visit while (or $9,000 per family). No one member will have to pay more than the outside the service area. See your subscriber certi昀椀cate for more information. per member deductible. Dependent Bene昀椀ts Your Out-of-Pocket Maximum This plan covers dependents until the end of the calendar month in which Your out-of-pocket maximum is the most that you could pay during a plan year they turn age 26, regardless of their 昀椀nancial dependency, student status, or for deductible, copayments, and coinsurance for covered services. Your employment status. See your subscriber certi昀椀cate (and riders, if any) for exact out-of-pocket maximum for medical and prescription drug bene昀椀ts is $6,450 coverage details. per member (or $12,900 per family). Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.