Network Blue New England Enhanced Value Plan Benefits At-A-Glance
Plan Specifics You Pay (In-Network Costs)
Plan-year deductible None
Plan-year out-of-pocket maximum $2,500 for an individual or $5,000 for a family
Benefit You Pay (In-Network Costs)
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning 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

When performed by other network providers

$35 per visit
Emergency room $150 per visit (copayment waived if admitted or for an observation stay)
Inpatient hospital care $500 per admission after deductible
Outpatient surgery  

Office or health center when performed by your PCP or OB/GYN

$20 per visit

Office or health center when performed by other network providers

$35 per visit

Ambulatory surgical facility, hospital, or surgical day care unit

$250 per admission
CT scans, MRIs, and other imaging tests $50 per category per date of service after deductible

 

Summary of Benefits Summary of Benefits
Subscriber Certificate 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. Covered medications are separated into three tiers, and the amount you pay depends on the medication's tier.

Prescription Drug Benefits You Pay (In-Network Costs)1
Retail pharmacies (up to a 30-day supply) $15 for Tier 12
$30 for Tier 2
$50 for Tier 3
Mail service pharmacy (up to a 90-day supply) $30 for Tier 12
$60 for Tier 2
$100 for Tier 3

 

1. Cost share waived for certain orally administered anticancer drugs

2. Cost share waived for birth control

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