Benefits - Woburn - Blue Cross Blue Shield of Massachusetts

Blue Care Elect Preferred (PPO) Benefits at a Glance

Plan Specifics	You Pay
Calendar-year deductible	In-network: $0 Out-of-network: $250 per member ($500 per family)
Benefit	You Pay
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning	Nothing
Office visits (sick care and non-preventive)	$20 per visit
Office visits (specialists)	$20 per visit
Emergency room	$75 per visit (waived if admitted or for observation stay)
Inpatient hospital care	Nothing

Dependent Benefits

This plan covers dependents up to age 26, regardless of the dependent's financial dependency, student status, or employment status.

Prescription Drug Coverage

Your plan includes prescription drug coverage.

Prescription Drug Coverage	You Pay (In-Network Costs)
Retail pharmacies	$10 for generic ¹ $20 for brand-name
Mail service pharmacy (up to a 90-day supply)	$20 for generic ¹ $40 for brand-name

1. Cost share waived for birth control.