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 a copayment of Massachusetts. Your deductible is $2,900 per individual membership per visit for in-network or out-of-network emergency room services. This (or $5,800 per family membership) for in-network and out-of-network services copayment is waived if you are admitted to the hospital or for an observation combined. The entire family deductible must be satisfied before benefits are stay. See the chart for your cost share. provided for any one member enrolled under a family membership. 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 covered by the health plan and the use of telehealth is appropriate. Your health you 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 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 or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you are still covered, but your on your ID card. 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/or your 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. Your they turn age 26, regardless of their financial dependency, student status, or out-of-pocket maximum for medical and prescription drug benefits is $6,450 employment status. See your subscriber certificate (and riders, if any) for exact per member (or $12,900 per family) for in-network and out-of-network coverage details. services combined. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.