Fiscal 2017 2018 MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO COMPARISON OF S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Comparison of the following Blue Cross Blue Shield of Massachusetts PPO medical plans: BLUE CARE ELECT VALUE PPO RATE SAVER BLUE CARE ELECT PREFERRED PPO BENCHMARK **EFFECTIVE 7/1/2017** **EFFECTIVE 7/1/2017**
Deductible None $250 per member per plan None $250 per member per plan $300 per member per Plan $300 per member per Plan $500 per family per plan $500 per family per plan $900 per family per Plan $900 per family per Plan (Plan year deductible (Plan year deductible combined for in and out of combined for in and out of network services) network services) Maximum Out of Pocket (MOOP)-Plan $2,000 per member/$4,000 per family (per plan year) for Medical benefits (Combined in and Out of Network) AND $3,000 per member/$6,000 per family (per plan year) for prescription drug benefits- MOOP is for all services except - premiums, balance-billed charges, and health care this plan doesn't cover. $2,000 per member/$4,000 per family (per plan $2,000 per member/$4,000 per family (per plan year) for year) for Medical benefits (Combined in and Out of Medical benefits (Combined in and Out of Network) AND Network) AND $3,000 per member/$6,000 per $3,000 per member/$6,000 per family (per plan year) for family (per plan year) for prescription drug benefits- prescription drug benefits- MOOP is for all services except - MOOP is for all services except - premiums, premiums, balance-billed charges, and health care this plan balance-billed charges, and health care this plan doesn't cover. doesn't cover. Eligible Dependents turns age 26, regardless of the dependency, student status, or employment status. turns age 26, regardless of the dependency, student status, or employment status. turns age 26, regardless of the dependent's financial dependency, student status, or employment status. turns age 26, regardless of the dependent's financial dependency, student status, or employment status. the month dependent turns age 26, regardless of the dependency, student status, or employment status. the month dependent turns age 26, regardless of the dependency, student status, or employment status. Service Area INPATIENT General Hospital, Mental Hospital, Substance Abuse Facility (semi-private room and board and special services) above allowed $250 per admission (including maternity care) above allowed $500 per admission General Hosp care $1500 per admission higher cost share Hosp. $200 per admission after ded for mental or substance abuse hosp above allowed Page 2 of 7
INPATIENT cont. Physician Services, Surgical Charges, Anesthesia and Consultations. Skilled Nursing Facility up to 100 days per plan year at a semiprivate room (benefit max combined for services in and out of network). (benefit max up to 100 days per plan year at a semiprivate room (benefit max combined for services in and out of network). (benefit max up to 100 days per plan year at at semi-private room (benefit max combined for services in & out of network) (benefit max and out of network). Rehabilitation Hospital to 60 days per plan year benefit maximum (benefit max (benefit max to 60 days per plan year benefit maximum (benefit max (benefit max to 60 days per plan year benefit maximum (benefit max combined for services in and out of network) above the allowed (benefit max OUTPATIENT HOSPITAL Emergency Room Visits for $50 copay (waived if Emergency or Accident Care admitted) $50 copay (waived if admitted) $100 copay (waived if admitted) $100 copay (waived if admitted) $100 copay after deductible (waived if admitted) $100 copay after deductible (waived if admitted) OutPatient Surgery in surgical facility, hospital or surgical daycare unit abovethe allowed $150 per admission at surgical facility, hospital or day care unit $250 per admission after deductible Radiation and Chemotherapy after deductible above the allowed Diagnostic X-ray & Lab after deductible above the allowed Page 3 of 7
OUTPATIENT CONT. High Tech Radiology (MRI, $25 copay per category $100 copay after deductible CT, PT Scans) per date of service (per category test, per date above (copay waived at freestanding of service)(copay waived at the allowed facilities) free-standing facilities) Hemodialysis after deductible above the allowed Physical Therapy $15 copay up to 100 visits per member per plan year combined with Out-Of-Network up to 100 visits services. per member per plan year combined with In- Network services $20 copay up to 100 visits per member per plan year combined with Out-Of-Network services. up to 100 visits per member per plan year combined with In- Network services $20 copay up to 60 visits (deductible does not apply) per member per plan year combined with Out of Network Services up to 60 visits per member per plan year combined with In- Network services PHYSICIAN'S OFFICE Office Visit- PCP Medical, Clinic, Mental Health Care, Substance Abuse Care Office Visit- Specialist Well Child Care Up to Age 19 $15 copay $15 copay $20 copay above the allowed 10 visits 1st year 10 visits 1st year 10 visits 1st year 10 visits 1st year 10 visits 1st year 10 visits 1st year 3 visits 2nd year 3 visits 2nd year 3 visits 2nd year 3 visits 2nd year 3 visits 2nd year 3 visits 2nd year 2 visits for age 2 2 visits for age 2 2 visits for age 2 2 visits for age 2 2 visits for age 2 2 visits for age 2 $20 copay $20 or $60 copay (depending on provider) $20 or $60 copay (depending on provider) above the allowed above the allowed from age 3-18 Adult Routine Physicals - Age 19 or over - 1 visit per member per plan year - 1 visit per member per plan year - 1 visit per member per plan year Page 4 of 7
PHYSICIAN'S OFFICE Routine GYN Exam-1 visit per calendar year Routine Colonoscopy (without surgery) - 1 visit per plan year above allowed - 1 visit per plan year above allowed - 1 visit per plan year above allowed Routine Mammogram -One baseline above allowed - One baseline -One baseline above allowed - One baseline -One baseline 5- year period in which the member is age 35-39 and one above allowed -One baseline mammogram during the the member is age 35-39 and one Routine Vision Exam - 1 visit per member per plan year - 1 visit per member every 24 months - 1 visit per member every 24 months Family Planning Services OTHER OUTPATIENT Visiting Nurse Home Health Care after deductible Hospice Services when arranged and authorized by a plan physician when arranged and authorized by a plan physician after deductible Page 5 of 7
Cardiac Rehabilitation (When medically necessary and authorized by a plan physician) Durable Medical Equipment $15 copay deductible 20% (no dollar max) (prosthetics covered in full with no maximum) deductible (prosthetics deductible) $20 copay 20% coinsurance (prosthetics covered in full) deductible (prosthetics deductible) $35 copay deductible (prosthetics 20% deductible) deductible (prosthetics 40% deductible) Ambulance (when medically necessary) Dental Care Not covered Not covered Not covered Not covered Not covered Not covered Chiropractor Visits Hearing Aids for accident or emergency; 20% other medically necessary ambulance transport $15 copay per visit - $2,000 per ear every 36 months (age deductible up to Benefit 21 or under) Benefit limit limit $20 copay per visit for accident or emergency; 20% other medically necessary ambulance transport - $2,000 per ear every 36 months (age 21 deductible up to Benefit or under) Benefit Limit limit after deductible $20 copay per visit (deductible does not apply) - $2,000 per ear every 36 months (age 21 or under) Benefit Limit (Not subject to deductible) after deductible for accident or emergency; 20% above the allowed for other medically necessary ambulance transport deductible up to Benefit limit Acupuncture Prescription Drugs $15 copay per visit - 12 visits per member per plan year (Deductible and/or coinsurance not applicable) Formulary drugs: Formulary drugs: Formulary drugs: Tier 1: $10 copay Tier 1: $10 copay Tier 1: $10 copay Tier 2: $20 copay Tier 2: $25 copay Tier 2: $30 copay Tier 3: $35 copay Tier 3: $45 copay Tier 3: $65 copay 30-day supply retail pharmacy or 90-day supply mail service Non-formulary drugs: all charges $20 copay per visit - 12 visits per member per plan year (Deductible and/or coinsurance not applicable) Mail order: Tier 1: $20 copay Tier 2: $50 copay Tier 3: $90 copay 30-day supply retail pharmacy or 90-day supply mail service Non-formulary drugs: all charges $20 copay per visit - 12 visits per member per plan year (Deductible and/or coinsurance not applicable) Mail order: Tier 1: $25 copay Tier 2: $75 copay Tier 3: $165 copay Non-formulary drugs: all charges Page 6 of 7
OTHER S Fitness Benefit/Special Programs - (See Plan for Details) Up to $300 reimbursement toward membership or exercise classes at a health club. reimbursement toward membership or exercise classes at a health club. counseling, counseling, personal personal Weight Watchers or hospital based weight your program fees. Weight Watchers or hospital based weight your program fees. MMHG Wellness Program "BENEFICIAL WELLNESS NEWS" QUARTERLY NEWSLETTER, WALKING PROGRAMS, MONTHLY HEALTH LINKS, WELLNESS SEMINARS/SCREENINGS, INCENTIVE PROGRAMS, FITNESS CENTER DISCOUNTS, WORKPLACE FLU CLINICS, HEALTHY RESOURCES POSTED ON OUR WEBSITE/FACEBOOK/TWITTER & MORE (PARTICIPATION IN CERTAIN PROGRAMS MAY VARY BY MEMBER UNIT. PLEASE CHECK WITH YOUR COORDINATOR OR WELLNESS COORDINATOR AND OUR WEBSITE -www.mmhg.org- FOR MORE INFORMATION) ANYTHING THAT APPEARS IN ITALIC BOLD TYPE INDICATES A CHANGE IN THE OR WORDING FROM THE PREVIOUS YEAR. Please note there are no waiting periods, lifetime benefit maximums or pre-existing exclusions for any of the MMHG health insurance plans. Disclaimer: This comparison summarizes benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s) & riders will govern. Please call the "member service" phone number on your ID card for specific coverage questions. Reviewed by Blue Cross Blue Shield of Massachusetts. Page 7 of 7