Network Blue New England Deductible Plan Benefits At-A-Glance
Plan Specifics You Pay (In-Network Enhanced Tier Costs) You Pay (In-Network Standard Tier Costs) You Pay (In-Network Basic Tier Costs)
Plan-year deductible None $250 for one member, $500 for two members, or $750 for a family
Plan-year out-of-pocket maximum $2,500 for an individual or $5,000 for a family
Benefit You Pay (In-Network Enhanced Tier Costs) You Pay (In-Network Standard Tier Costs) You Pay (In-Network Basic Tier Costs)
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning Nothing Nothing Nothing
Office visits (sick care or non-preventive)      

When performed by your primary care provider (PCP), OB/GYN, network nurse practitioner, physician assistant, nurse midwife, or mental health or substance abuse provider

$20 per visit

$20 per visit

$20 per visit

When performed by other network providers

$35 per visit

$35 per visit

$35 per visit
Emergency room $100 per visit (waived if admitted or for observation stay) $100 per visit (waived if admitted or for observation stay) $100 per visit (waived if admitted or for observation stay)
Inpatient hospital care $300 per admission1 $300 per admission $700 per admission
Outpatient surgery      

Office setting: PCP / Other network providers

$20 per visit2 / $35 per visit2

$20 per visit2 / $35 per visit2

$20 per visit2 / $35 per visit2

Surgical day care unit

$150 per admission

$150 per admission; $200 per admission at selected hospitals1

$150 per admission after deductible

Ambulatory surgical facility

$150 per admission

$150 per admission

$150 per admission
CT scans, MRIs, and other imaging tests      

General hospitals

$50 per category per date of service

$50 per category per date of service1

$50 per category per date of service after deductible

Other covered providers

$50 per category per date of service

$50 per category per date of service1

$150 per admission after deductible

 

1. The selected Standard Benefits Tier hospitals noted in this chart include Athol Memorial Hospital, Baystate Franklin Medical Center, Baystate Mary Lane Hospital, Falmouth Hospital, Martha's Vineyard Hospital, Nantucket Cottage Hospital, and North Adams Regional Hospital. The deductible does not apply for any covered services furnished by these hospitals.

2. The copayment is waived for restorative dental service and orthodontic treatment or prosthetic management therapy for members under age 18 to treat cleft lip and cleft palate.

Summary of Benefits Summary of Benefits
Summary of Benefits Summary of Benefits + Coverage
Dependent Benefits

This plan covers dependents up to the age of 26, even if they aren't considered dependents on a tax return, don't attend school, and regardless of whether or not they have a job—unless they are eligible for coverage under a non-parent, employer-sponsored plan.

Prescription Drug Coverage

Your plan includes prescription drug coverage.

Prescription Drug Benefits You Pay (In-Network Enhanced Tier Costs)1 You Pay (In-Network Standard Tier Costs)1 You Pay (In-Network Basic Tier Costs)1
Retail pharmacies (up to a 30-day supply) $10 for Tier 12
$25 for Tier 2
$50 for Tier 3 		$10 for Tier 12
$25 for Tier 2
$50 for Tier 3 		$10 for Tier 12
$25 for Tier 2
$50 for Tier 3
Mail service pharmacy (up to a 90-day supply) $20 for Tier 12
$50 for Tier 2
$110 for Tier 3 		$20 for Tier 12
$50 for Tier 2
$110 for Tier 3 		$20 for Tier 12
$50 for Tier 2
$110 for Tier 3

 

1. Cost share waived for certain orally administered anticancer drugs

2. Cost share waived for birth control

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