Network Blue New England Deductible (HMO) Benefits at a Glance
Plan Specifics You Pay
Calendar-year deductible $375 (member), $875 (family)
Calendar-year Out-of-Pocket Maximum $5,000 (member), $10,000 (family)
Benefit You Pay
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning Nothing, no deductible
Office visits (sick care/non-preventive) $15 per visit, no deductible
Office visits (specialists) $30 per visit, no deducible
Emergency room $100 per visit after deductible (waived if admitted or for an observation stay)
Inpatient hospital care Nothing after deductible

 

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Dependent Benefits

This plan covers dependents to the end of the month in which the dependent turns 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.

Prescription Drug Coverage

Your plan includes prescription drug coverage. Covered medications are separated into three tiers, and the amount you pay depends on the medication's tier.

Prescription Drug Benefits You Pay
Retail pharmacies (up to a 30-day supply)

$10 for Tier 11
$25 for Tier 2
$40 for Tier 3
Mail service pharmacy (up to a 90-day supply)

$10 for Tier 11
$25 for Tier 2
$40 for Tier 3

1. Cost share waived for birth control.

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