Your Choice Your Deductible Telehealth Services Your deductible is the amount of money you pay out-of-pocket each Telehealth services are covered when the same in-person service would be plan year before you can receive coverage for certain bene昀椀ts under this plan. covered by the health plan and the use of telehealth is appropriate. Your health If you are not sure when your plan year begins, contact Blue Cross Blue Shield of care provider will work with you to determine if a telehealth visit is medically Massachusetts. Your deductible is $4,000 per member (or $8,000 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. No one member will of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website have to pay more than the per member deductible. at bluecrossma.org, consult Find a Doctor, or call the Member Service number on your ID card. When You Choose Preferred Providers You receive the highest level of bene昀椀ts under your health care plan when Your Virtual Care Team you obtain covered services from preferred providers. These are called your Your health plan includes an option for a tech-enabled primary care delivery “in-network” bene昀椀ts. See the charts for your cost share. 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 services. See your subscriber certi昀椀cate (and riders, if any) for exact coverage details. or specialist), make sure the provider is a preferred provider in order to receive bene昀椀ts at the in-network level. If the provider you use is not a preferred provider, you’re still covered, but your bene昀椀ts, in most situations, will be covered at the out-of-network level, even if the preferred Utilization Review Requirements provider refers you. Certain services require pre-approval/prior authorization through Blue Cross How to Find a Preferred Provider Blue Shield of Massachusetts for you to have bene昀椀t coverage; this includes non-emergency and non-maternity hospitalization and may include certain To 昀椀nd a preferred provider: • Look up a provider on Find a Doctor at bluecrossma.com/昀椀ndadoctor. 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 it’s required, your bene昀椀ts will be denied, and you may be fully responsible for • Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org payment to the provider of the service. Refer to your subscriber certi昀椀cate for requirements and the process you should follow for Utilization Review, including When You Choose Non-Preferred Providers Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge You can also obtain covered services from non-preferred providers, but your Planning, and Individual Case Management. out-of-pocket costs are higher. These are called your “out-of-network” bene昀椀ts. See the charts for your cost share. Dependent Bene昀椀ts This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their 昀椀nancial dependency, student status, or Payments for out-of-network bene昀椀ts are based on the Blue Cross Blue Shield employment status. See your subscriber certi昀椀cate (and riders, if any) for exact allowed charge as de昀椀ned in your subscriber certi昀椀cate. You may be responsible for any difference between the allowed charge and the provider’s actual billed coverage details. charge (this is in addition to your deductible and/or your coinsurance). Domestic Partner Coverage Your Out-of-Pocket Maximum Domestic partner coverage may be available for eligible dependents. Contact Your out-of-pocket maximum is the most that you could pay during a plan your plan sponsor for more information. year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical and prescription drug bene昀椀ts is $6,450 per member (or $12,900 per family) for in-network and out-of-network services 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. This copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your cost share.