Understanding Your Plan

The power of Blue Options is the way the provider network works. You get complete access to the entire Blue Cross Blue Shield of Massachusetts network and you have the ability to control what you pay for care.

In Massachusetts
With Blue Options, doctors and hospitals in Massachusetts are grouped into three benefit levels—or tiers. Your out-of-pocket costs are based on the tiers of your doctors and hospitals.

  • Enhanced Benefits Tier—Lowest costs for you - Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for lowest cost.

  • Standard Benefits Tier—Mid-level costs for you - Includes Massachusetts PCPs and hospitals that met our quality benchmark and our benchmark for moderate cost. Also includes providers without sufficient data for measurement on one or both benchmarks. In limited circumstances, the Standard Benefits Tier includes certain providers whose scores would put them in the Basic Benefits Tier to provide geographic access for members.

  • Basic Benefits Tier—The highest costs for you - Includes Massachusetts PCPs and hospitals that scored below our quality benchmark and/or our benchmark for moderate cost.

You can choose providers from the Enhanced Benefits Tier and pay less—often substantially less—or select providers from other tiers and pay more. The choice is always yours.

Tiering applies to most of your care, including:

  • Doctor's office visits
  • Regular checkups and annual physicals
  • Surgery and hospital admittance
  • Labs and radiology tests

But, there are a few exceptions, including:

  • Emergency room care—You can't always choose where you seek care when you go to the E.R., so you'll always pay the same Enhanced Benefits Tier copayment, regardless of who provides you with care
  • Prescription drugs—Your medications are subject to standard pharmacy tiering

To learn more about your plan and its benefits, like what health care services are covered under your plan and their related out-of-pocket costs, visit the Plan Details section.

Want to learn more about tiers?
How Providers Are Tiered has what you want to know about the methodology behind the Blue Options benefit tiers, including the detailed definition of each tier and what types of data are used in determining the overall cost and quality score of a provider.

Note: PCPs were measured based on their HMO patients as part of their provider group, and hospitals were measured based on their individual facility performance. Provider groups can be composed of an individual provider, or a number of providers who practice together. Tier placement is based on cost and quality benchmarks where measurable data is available. Providers without sufficient data for either cost or quality are placed in the Standard Benefits Tier. Providers that do not meet benchmarks for one or both of the domains and hospitals that use nonstandard reimbursement are placed in the Basic Benefits Tier.