Your Care Access Telehealth Services This plan gives you the option to go directly to a specialist or any doctor in the Telehealth services are covered when the same in-person service would be HMO Blue New England network without a referral. Just show your Blue Cross covered by the health plan and the use of telehealth is appropriate. Your health Blue Shield of Massachusetts ID card and receive care. However, some services care provider will work with you to determine if a telehealth visit is medically do require authorization. See your subscriber certificate for details. appropriate for your health care needs or if an in-person visit is required. For a list of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website Primary Care Provider (PCP) at bluecrossma.org, consult Find a Doctor, or call the Member Service number When you enroll in this health plan, you must choose a primary care provider. Be on your ID card. sure to select a doctor who is accepting you and your family members as new patients and participates in our network of providers in New England. For children, Your Virtual Care Team you may designate a participating network pediatrician as the PCP. Your health plan includes the option for a tech-enabled delivery model where virtual care team covered providers furnish certain covered services, including For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross primary care with integrated mental health and/or substance use care within Blue Shield of Massachusetts website at bluecrossma.org; consult Find a Doctor the patient care team, via traditional and/or digital platforms (such as: mobile at bluecrossma.com/findadoctor; or call the Member Service number on your app; web portal; telephone; and/or text message). This care delivery model ID card. offers a comprehensive and coordinated primary care experience with virtual engagement and seamless navigation to in-person care with network providers If you have trouble choosing a doctor, Member Service can help. They can give when applicable. After meeting your deductible, for outpatient covered you the doctor’s gender, the medical school the doctor attended, and whether services furnished by a designated virtual care team primary care or mental there are languages other than English spoken in the office. health care provider type, you will pay nothing (any deductible, copayment, Your provider may also work with Blue Cross Blue Shield of Massachusetts and/or coinsurance does not apply). For outpatient covered services regarding Utilization Review Requirements, including Pre-Admission Review, furnished by a virtual care team covered provider that is not a virtual care Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient team primary care or mental health care provider type, you will pay your Services, and Individual Case Management. For detailed information about applicable cost share (deductible, copayment, and/or coinsurance). To find Utilization Review, see your subscriber certificate. a virtual care team covered provider or to learn more about this care delivery model, visit MyBlue online or see “When You Need Help to Find a Health Care Your Deductible Provider” in your subscriber certificate, or call the Member Service number on Your deductible is the amount of money you pay out-of-pocket each plan your ID card. year before you can receive coverage for certain benefits under this plan. If Service Area you are not sure when your plan year begins, contact Blue Cross Blue Shield The plan’s service area includes all cities and towns in the Commonwealth of of Massachusetts. Your deductible is $4,500 per member (or $9,000 per family). Massachusetts, State of Rhode Island, State of Vermont, State of Connecticut, Your Out-of-Pocket Maximum State of New Hampshire, and State of Maine. Your out-of-pocket maximum is the most that you could pay during a plan year When Outside the Service Area for deductible, copayments (including prescription drug copayments), and If you’re traveling outside the service area and you need urgent or emergency coinsurance for covered services. Your out-of-pocket maximum is $6,450 per care, you should go to the nearest appropriate health care facility. You are member (or $12,900 per family). covered for the urgent or emergency care visit and one follow-up visit while Emergency Room Services outside the service area. See your subscriber certificate for more information. In an emergency, such as a suspected heart attack, stroke, or poisoning, Dependent Benefits you should go directly to the nearest medical f acility or call 911 (or the local This plan covers dependents until the end of the calendar month in which emergency phone number). After meeting your deductible, you pay a copayment they turn age 26, regardless of their financial dependency, student status, or per visit for emergency room services. This copayment is waived if you are employment status. See your subscriber certificate (and riders, if any) for exact admitted to the hospital or for an observation stay. See the chart for your coverage details. cost share. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.