Your Choice Your Deductible Emergency Room Services Your deductible is the amount of money you pay out-of-pocket each In an emergency, such as a suspected heart attack, stroke, or poisoning, plan year before you can receive coverage for certain benefits under this plan. you should go directly to the nearest medical facility or call 911 (or the local If you are not sure when your plan year begins, contact Blue Cross Blue Shield emergency phone number). After meeting your deductible, you pay nothing for of Massachusetts. Your deductible is $4,000 per member (or $8,000 per family) in-network or out-of-network emergency room services. for in-network and out-of-network services combined. Telehealth Services When You Choose Preferred Providers Telehealth services are covered when the same in-person service would be You receive the highest level of benefits under your health care plan when you covered by the health plan and the use of telehealth is appropriate. Your health obtain covered services from preferred providers. These are called your care provider will work with you to determine if a telehealth visit is medically “in-network” benefits. See the charts for your cost share. appropriate for your health care needs or if an in-person visit is required. For a list Note: If a preferred provider refers you to another provider for covered services (such as a lab or of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website specialist), make sure the provider is a preferred provider in order to receive benefits at the at bluecrossma.org, consult Find a Doctor, or call the Member Service number in-network level. If the provider you are referred to is not a preferred provider, you are still covered, on your ID card. but your benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. Your Virtual Care Team How to Find a Preferred Provider Your health plan includes an option for a tech-enabled primary care delivery model where virtual care team covered providers furnish certain covered To find a preferred provider: • Look up a provider on Find a Doctor at bluecrossma.com/findadoctor. If you services. See your subscriber certificate (and riders, if any) for exact need a copy of your directory or help choosing a provider, call the Member coverage details. Service number on your ID card. Utilization Review Requirements • Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org Certain services require pre-approval/prior authorization through Blue Cross Blue Shield of Massachusetts for you to have benefit coverage; this includes When You Choose Non-Preferred Providers non-emergency and non-maternity hospitalization and may include certain You can also obtain covered services from non-preferred providers, but your outpatient services, therapies, procedures, and drugs. You should work with your health care provider to determine if pre-approval is required for any service out-of-pocket costs are higher. These are called your “out-of-network” benefits. See the charts for your cost share. your provider is suggesting. If your provider, or you, don’t get pre-approval when 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 Payments for out-of-network benefits are based on the Blue Cross Blue Shield requirements and the process you should follow for Utilization Review, including allowed charge as defined in your subscriber certificate. You may be responsible for any difference between the allowed charge and the provider’s actual billed Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge charge (this is in addition to your deductible and coinsurance). Planning, and Individual Case Management. Your Out-of-Pocket Maximum Dependent Benefits Your out-of-pocket maximum is the most that you could pay during a plan This plan covers dependents until the end of the calendar month in which year for deductible, copayments, and coinsurance for covered services. they turn age 26, regardless of their financial dependency, student status, or Your out-of-pocket maximum for medical benefits is $7,000 per member employment status. See your subscriber certificate (and riders, if any) for exact (or $14,000 per family) for in-network and out-of-network services combined. coverage details. 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. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.