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2014 Medical and Dental Plan Comparison Chart

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(1)

Benefits for Residents

(2)

This chart is only a summary. For details, limitations, and exclusions, please contact your Professional Staff Benefits Office for the specific plan’s benefit description.

PARTNERS PLUS

Partners Preferred Network

BCBS Plan Network

Out-of-Network

G

ENERAL

P

ROVISIONS

Annual Deductible (individual/family) The Plan’s Coinsurance

Out-of-Pocket Maximum (individual/family)1

Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit

I

NPATIENT

M

EDICAL AND

S

URGICAL

S

ERVICES

Per Admission Co-Pay

Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing

I

NPATIENT

M

ENTAL

H

EALTH AND

S

UBSTANCE

A

BUSE

S

ERVICES

Inpatient Mental Health and Substance Abuse

O

UTPATIENT

C

OVERED

S

ERVICES

Primary Care Physician Office Visits Specialist Office Visits

Routine Physicals2

Other Preventive Care2

Hospital Outpatient Emergency Room Visit

Prescriptions –Express Scripts at participating pharmacies1

60-Day co-pays: $20/$60/$100

90-Day home delivery co-pays: $20/$60/$100 Outpatient Surgery

Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18)2

Immunizations and Inoculations (adult)2

Pap Smear2

Routine Mammogram (one baseline mammogram between ages 35–39; one mammogram per year after age 40)2

Hearing Exams2

Hearing Aids and Batteries1,3

Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy

Speech Therapy

Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment

M

ATERNITY

C

OVERAGE

In-Hospital (Delivery) Out-of-Hospital (prenatal care)

O

THER

S

ERVICES

Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services None 100% Required Recommended Unlimited N/A 100% 100% Not covered 100% $15 $15 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $15 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $0 co-pay; 100%

Up to $1,000 per year (combined) 100%

100%

$15 co-pay; 100%(100 visits per calendar year) $15 co-pay; 100% $15 co-pay; 100% 80% 100% $15 co-pay; 100% 100% $0 co-pay; 100% 100% 100% 100% $15 co-pay; 100% Not covered

$15 co-pay; 100%(limited services only)

$250/$500 100% Required Recommended Unlimited $250 after deductible 100% after deductible 100% after deductible Not covered 100% $15 $40 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $40 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name $150 co-pay; 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $0 co-pay; 100%

Up to $1,000 per year (combined) 100%

$150 co-pay; 100%

$40 copay(visits 1-15); $15 co-pay (visits 16-100) (100 visits per calendar year)

$40 copay(visits 1-15); $15 co-pay (visits 16+) $15 co-pay; 100%

80% 100% $40 co-pay

$250 per admission after deductible $0 co-pay; 100% 100% 100% 100% $40 co-pay; 100% 80% after deductible

$15 co-pay; 100%(limited services only)

$500/$1,000 70% $4,000/$8,0001 Required Recommended Unlimited Deductible applies 70% after deductible 70% after deductible Not covered 70% after deductible 70% after deductible 70% after deductible Not covered 70% after deductible 70% after deductible $100 copay (waived if admitted) Up to 30-Day Supply4 $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 70% after deductible 70% after deductible

70% after deductible (to age 5 only) 70% after deductible

70% after deductible

70% after deductible (according to schedule) 70% after deductible

Up to $1,000 per year (combined) 70% after deductible

70% after deductible

70% after deductible(100 visits per calendar year) 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible

70% after deductible(limited services only)

1This is a combined out-of-pocket maximum for the Partners Preferred and Plan Networks. Prescription drug and hearing aid co-pays do not count toward the out-of-pocket maximum.

2 No co-pay for in-network preventive care described under the Affordable Care Act; co-pay applies if regular office visit includes non-preventive care. "Preventive care" includes most routine physical exams and preventive

preventive lab tests; family planning services (including contraception); routine Prostate-Specific Antigen (PSA) testing; and routine sigmoidoscopies/colonoscopies, except where surgical removal takes place,which is subject to

3Hearing aids are covered up to age 22 under the state mandate. Coverage is $2,000 per ear every 36 months for all plans. In addition, Partners Plus and Partners Value provide coverage of $1,000 per year from age 22 on. 4Most pharmacies are In-Network for Express Scripts. No coverage is available for an Out-of-Network pharmacy.

(3)

PARTNERS VALUE

Partners Preferred Network BCBS Plan Network Out-of-Network

G

ENERAL

P

ROVISIONS

Annual Deductible (individual/family) The Plan’s Coinsurance

Out-of-Pocket Maximum (individual/family)1

Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit

I

NPATIENT

M

EDICAL AND

S

URGICAL

S

ERVICES

Per Admission Co-Pay

Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing

I

NPATIENT

M

ENTAL

H

EALTH AND

S

UBSTANCE

A

BUSE

S

ERVICES

Inpatient Mental Health and Substance Abuse

O

UTPATIENT

C

OVERED

S

ERVICES

Primary Care Physician Office Visits Specialist Office Visits

Routine Physicals2

Other Preventive Care2

Hospital Outpatient Emergency Room Visit

Prescriptions – Express Scripts at participating pharmacies1

60-Day co-pays: $20/$60/$100 90-Day home delivery co-pays: $20/$60/$100 Outpatient Surgery

Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18)2

Immunizations and Inoculations (adult)2

Pap Smear2

Routine Mammogram (one baseline mammogram between ages 35–39; one mammogram per year after age 40)2

Hearing Exams2

Hearing Aids and Batteries1,3

Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy

Speech Therapy

Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment

M

ATERNITY

C

OVERAGE

In-Hospital (Delivery) Out-of-Hospital (prenatal care)

O

THER

S

ERVICES

Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services None 80% Required Recommended Unlimited $250 80% 80% Not covered 80% $35 $35 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $35 co-pay; 100%

$100 copay (waived if admitted)

Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $0 co-pay; 100%

Up to $1,000 per year (combined) 100%

100%

$35 co-pay; 100% (100 visits per calendar year) $35 co-pay; 100% $35 co-pay; 100% 80% 100% $35 co-pay; 100% 80% $0 co-pay; 100% 80% 100% 100% $35 co-pay; 100% Not covered

$35 co-pay; 100% (limited services only)

$500/$1,000 75% Required Recommended Unlimited $250 after deductible 75% after deductible 75% after deductible Not covered 75% after deductible $35 $50 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $50 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name $200 co-pay; 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $0 co-pay; 100%

Up to $1,000 per year (combined) 100%

$150 co-pay; 100%

$50 copay (visits 1-15); $35 co-pay (visits 16-100) (100 visits per calendar year)

$50 copay (visits 1-15); $35 co-pay (visits 16+) $35 co-pay; 100%

80% 100% $50 co-pay

$250 per admission after deductible; 75% $0 co-pay; 100% 80% 100% 100% $50 co-pay; 100% 75% after deductible

$35 co-pay; 100% (limited services only)

$750/$1,500 65% $5,000/$10,000 Required Recommended Unlimited Deductible applies 65% after deductible 65% after deductible Not covered 65% after deductible 65% after deductible 65% after deductible Not covered 65% after deductible 65% after deductible $100 copay (waived if admitted) Up to 30-Day Supply4 $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 65% after deductible 65% after deductible

65% after deductible (to age 5 only) 65% after deductible

65% after deductible

65% after deductible (according to schedule) 65% after deductible

Up to $1,000 per year (combined) 65% after deductible

65% after deductible

65% after deductible (100 visits per calendar year) 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible 65% after deductible

65% after deductible (limited services only) screenings for adults and children; well-child care; preventive immunizations; preventive Pap smears and mammograms; routine gynecology visits; routine vision exams; routine hearing exam office visits and hearing tests; deductible, co-pay and/or coinsurance. Frequency of coverage for services will be based on preventive screening guidelines referenced by the Affordable Care Act.

(4)

Partners Preferred Network

HPHC Plan Network

HARVARD PILGRIM HEALTH CARE

G

ENERAL

P

ROVISIONS

Annual Deductible (individual/family) The Plan’s Coinsurance

Out-of-Pocket Maximum (individual/family)1

Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit

I

NPATIENT

M

EDICAL AND

S

URGICAL

S

ERVICES

Per Admission Co-Pay

Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing

I

NPATIENT

M

ENTAL

H

EALTH AND

S

UBSTANCE

A

BUSE

S

ERVICES

Inpatient Mental Health and Substance Abuse

O

UTPATIENT

C

OVERED

S

ERVICES

Primary Care Physician Office Visits Specialist Office Visits

Routine Physicals2

Other Preventive Care2

Hospital Outpatient Emergency Room Visit

Prescriptions –Express Scripts at participating pharmacies1

60-Day co-pays: $20/$60/$100

90-Day home delivery co-pays: $20/$60/$100 Outpatient Surgery

Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18)2

Immunizations and Inoculations (adult)2

Pap Smear2

Routine Mammogram (one baseline mammogram between ages 35–39; one mammogram per year after age 40)2

Hearing Exams2

Hearing Aids and Batteries1,3

Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy

Speech Therapy

Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment

M

ATERNITY

C

OVERAGE

In-Hospital (Delivery) Out-of-Hospital (prenatal care)

O

THER

S

ERVICES

Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services None 100% Required Recommended Unlimited N/A 100% 100% Not covered 100% $15 $15 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $15 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $15 co-pay; 100%

Not covered 100% 100%

$15 co-pay; 100%(100 visits per calendar year) $15 co-pay; 100% $15 co-pay; 100% 80% 100% $15 co-pay; 100% 100% $0 co-pay; 100%

100% (100 days per year maximum) 100%

100% $15 co-pay; 100%

$15 co-pay (up to 12 visits per year) Not covered(limited services only)

$250/$500 100% Required Recommended Unlimited $250 after deductible 100% after deductible 100% after deductible Not covered 100% after deductible $15 $40 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $40 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply4 $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name $150 co-pay; 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $40 co-pay; 100%

Not covered 100%

$150 co-pay; 100%

$40 copay(visits 1-15); $15 co-pay(visits 16-100) (100 visits per calendar year)

$40 copay(visits 1-15); $15 co-pay(visits 16+) $15 co-pay; 100%

80% 100% $40 co-pay

$250 per admission after deductible $0 co-pay; 100%

100% (100 Days per year maximum) 100%

100% $40 co-pay; 100%

$15 co-pay (up to 12 visits per year) Not covered(limited services only) $2,500/$5,000 combined maximum1

1This is a combined out-of-pocket maximum for the Partners Preferred and Plan Networks. Prescription drug and hearing aid co-pays do not count toward the out-of-pocket maximum.

2 No co-pay for in-network preventive care described under the Affordable Care Act; co-pay applies if regular office visit includes non-preventive care. "Preventive care" includes most routine physical exams and preventi

co-pay and/or coinsurance. Frequency of coverage for services will be based on preventive screening guidelines referenced by the Affordable Care Act.

(5)

TUFTS HEALTH PLAN

Partners Preferred Network

Tufts Plan Network

G

ENERAL

P

ROVISIONS

Annual Deductible (individual/family) The Plan’s Coinsurance

Out-of-Pocket Maximum (individual/family)1

Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit

I

NPATIENT

M

EDICAL AND

S

URGICAL

S

ERVICES

Per Admission Co-Pay

Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing

I

NPATIENT

M

ENTAL

H

EALTH AND

S

UBSTANCE

A

BUSE

S

ERVICES

Inpatient Mental Health and Substance Abuse

O

UTPATIENT

C

OVERED

S

ERVICES

Primary Care Physician Office Visits Specialist Office Visits

Routine Physicals2

Other Preventive Care2

Hospital Outpatient Emergency Room Visit

Prescriptions –Express Scripts at participating pharmacies1

60-Day co-pays: $20/$60/$100

90-Day home delivery co-pays: $20/$60/$100 Outpatient Surgery

Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18)2

Immunizations and Inoculations (adult)2

Pap Smear2

Routine Mammogram (one baseline mammogram between ages 35–39; one mammogram per year after age 40)2

Hearing Exams2

Hearing Aids and Batteries1,3

Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy

Speech Therapy

Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment

M

ATERNITY

C

OVERAGE

In-Hospital (Delivery) Out-of-Hospital (prenatal care)

O

THER

S

ERVICES

Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services None 100% Required Recommended Unlimited N/A 100% 100% Not covered 100% $15 $15 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $15 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $15 co-pay; 100%

Not covered 100% 100%

$15 co-pay; 100% (100 visits per calendar year) $15 co-pay; 100% $15 co-pay; 100% 80% 100% $15 co-pay; 100% 100% $0 co-pay; 100% 100% 100% with authorization 100%

$15 co-pay; 100% up to 100 days per year maximum with authorization $15 co-pay; 100% (up to 12 visits per year)

Not covered(limited services only)

$250/$500 100% Required Recommended Unlimited $250 after deductible 100% after deductible 100% after deductible Not covered 100% after deductible $15 $40 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $40 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply4 $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name $150 co-pay; 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $40 co-pay; 100%

Not covered 100%

$150 co-pay; 100%

$40 copay (visits 1-15); $15 co-pay (visits 16-100) (100 visits per calendar year)

$40 copay (visits 1-15); $15 co-pay (visits 16+) $15 co-pay; 100%

80% 100% $40 co-pay

$250 per admission after deductible $0 co-pay; 100%

100%

100% with authorization 100%

$40 co-pay; 100% up to 100 days per year maximum with authorization $15 co-pay; 100% (up to 12 visits per year)

Not covered(limited services only) $2,500/$5,000 combined maximum1

ve screenings for adults and children; well-child care; preventive immunizations; preventive Pap smears and mammograms; routine gynecology visits; routine vision exams; routine hearing exam office visits and hearing tests; preventive lab te

(6)

NEIGHBORHOOD HEALTH PLAN

Partners Preferred Network

NHP Plan Network

G

ENERAL

P

ROVISIONS

Annual Deductible (individual/family) The Plan’s Coinsurance

Out-of-Pocket Maximum (individual/family)1

Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit

I

NPATIENT

M

EDICAL AND

S

URGICAL

S

ERVICES

Per Admission Co-Pay

Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing

I

NPATIENT

M

ENTAL

H

EALTH AND

S

UBSTANCE

A

BUSE

S

ERVICES

Inpatient Mental Health and Substance Abuse

O

UTPATIENT

C

OVERED

S

ERVICES

Primary Care Physician Office Visits Specialist Office Visits

Routine Physicals2

Other Preventive Care2

Hospital Outpatient Emergency Room Visit

Prescriptions –Express Scripts at participating pharmacies1

60-Day co-pays: $20/$60/$100

90-Day home delivery co-pays: $20/$60/$100 Outpatient Surgery

Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18)2

Immunizations and Inoculations (adult)2

Pap Smear2

Routine Mammogram (one baseline mammogram between ages 35–39; one mammogram per year after age 40)2

Hearing Exams2

Hearing Aids and Batteries1,3

Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy

Speech Therapy

Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment

M

ATERNITY

C

OVERAGE

In-Hospital (Delivery) Out-of-Hospital (prenatal care)

O

THER

S

ERVICES

Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services None 100% Required Required Unlimited N/A 100% 100% Not covered 100% $15 $15 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $15 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $15 co-pay; 100%

Not covered 100% 100%

$15 co-pay; 100% (100 visits per calendar year) $15 co-pay; 100% $15 co-pay; 100% 80% 100% $0 co-pay; 100% 100% $0 co-pay; 100%

100% (100 days per year maximum) 100%

100% when approved $15 co-pay; 100% Not covered

$15 co-pay; 100%(limited services only)

$250/$500 100% Required Required Unlimited $250 after deductible 100% after deductible 100% after deductible Not covered 100% after deductible $15 $40 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $40 co-pay; 100%

$100 copay (waived if admitted) Up to 30-Day Supply4 $10 co-pay–generic drugs $30 co-pay–preferred brand-name $50 co-pay–non-preferred brand-name $150 co-pay; 100% 100% $0 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100%

$0 co-pay; 100% (according to schedule) $40 co-pay; 100%

Not covered 100%

$150 co-pay; 100%

$40 copay, 100% (visits 1-15); $15 co-pay (visits 16-100) (100 visits per calendar year)

$40 copay, 100% (visits 1-15); $15 co-pay (visits 16+) $15 co-pay; 100%

80% 100% $40 co-pay; 100%

$250 per admission after deductible $0 co-pay; 100%

100% (100 days per year maximum) 100%

100% when approved $40 co-pay; 100% Not covered

80% after deductible(limited services only) $2,500/$5,000 combined maximum1

(7)

DDEENNTTAALL SSEERRVVIICCEESS

BBAASSIICC DDEENNTTAALL

M

MAAJJOORR DDEENNTTAALL

Calendar-year maximum

$1,000 per person $2,000 per person

(excluding orthodontia)

DDiiaaggnnoossttiicc//PPrreevveennttiivvee SSeerrvviicceess

Complete Initial Exam and Charting — once

Periodic oral — twice per calendar year

X-Rays: full mouth — every 60 months;

bitewings — twice per calendar year

Single tooth X-rays as needed

Comprehensive evaluation — every 60 months per dentist

Preventive Services

Teeth cleaning — twice per calendar year

Fluoride treatment — twice per calendar year for members under age 19

Space maintainers — Required due to the premature loss of teeth. For members under age 14

and not for the replacement of primary or permanent anterior teeth.

Sealants for unrestored permanent molars — every 4 years per tooth for members through age 15.

Sealants are also covered for members aged 16 up to age 19 who have had a recent cavity

and are at risk for decay.

Periodontal cleaning — once every 3 months following active periodontal treatment, not to be

combined with preventive cleanings.

M

Miinnoorr RReessttoorraattiivvee

Restorative Services

Silver and white fillings — once every 24 months per surface, per tooth

Temporary fillings — once per tooth

Stainless steel crowns — once every 24 months per tooth

Oral Surgery

Simple extractions (non-surgical) in dentist’s office

Surgical extractions (including impactions) in dentist’s office

(Oral surgical benefits not provided when rendered

in a surgical day care or hospital setting)

Periodontics

Scaling and root planing — once in 24 months, per quadrant

Periodontal Surgery — in dentist’s office (Periodontal surgery benefits not

provided when rendered in a surgical day care or hospital setting)

Endodontics

Root canal therapy — once per tooth

Vital pulpotomy — limited to deciduous teeth

Prosthetic Maintenance

Bridge or denture repairs — once every 12 months, same repair

Rebase of dentures — once every 36 months

Recementing crowns and onlays — once per tooth

Emergency Dental Care

Minor treatment for pain relief — three occurrences in 12 months

General anesthesia (only with covered surgical services)

M

Maajjoorr RReessttoorraattiivvee

Prosthodontics

Dentures — once within 60 months

Fixed bridges and crowns (when part of a bridge) — once every 60 months

Implants — once every 60 months per tooth

Restorative Services

Crowns and onlays (when teeth cannot be restored with regular fillings)

— once every 60 months per tooth

OOrrtthhooddoonnttiiaa

Active orthodontic treatment

Lifetime orthodontia maximum

50% Coverage,

after plan deductible

50% coverage, no

deductible, $2,000

lifetime maximum

not available

50% Coverage,

after plan deductible

After a $25

Individual Annual

Deductible,

$50 Family,

80% Coverage

After a $50

Individual Annual

Deductible,

$100 Family,

50% Coverage

100%

Coverage

No

Deductible

100%

Coverage

No

Deductible

(8)

MEDICAL PLAN HIGHLIGHTS FOR

2014

Each plan has a network known as the Partners Preferred Network. If you want to pay the lowest out-of-pocket claim costs, use a Partners Preferred (or affiliated) Network specialist and facility for your care.

Even if you do not use a Partners Preferred Network specialist or facility, you can still receive comprehensive

care, with minimal out-of-pocket claim costs, by using specialists and facilities within your insurance carrier’s Plan Network.

Primary care physician (PCP) visits, and mental health/substance abuse co-payments and deductibles, cost

the same in the Partners Preferred and Plan Networks.

You do not need to get an insurance referral from your PCP in order to receive coverage for specialist visits and other services. Your insurance carrier does not track your PCP in their files. However, you are encouraged to select a PCP to serve as a “home base” for your medical care.

Emergency room co-payments are $100, regardless of plan or network. This co-payment is waived if you are

admitted.

There are no costs for X-rays or lab tests, regardless of whether you receive the tests at a Partners or non-Partners facility. However, your co-payments and deductibles for physical therapy, inpatient admissions, outpatient surgery, and high-cost, ambulatory imaging (MRIs, CT scans and PET scans) will be higher when you use non-Partners specialists and facilities.

For more information about the plans’ networks, or to check your provider’s network status, please visit the

following websites:

B L U E C RO S S B L U E S H I E L D (for Partners Plus, Partners Value)

W W W. B L U E C RO S S M A . C O M / PA R T N E R S 1 - 8 8 8 - 2 1 1 - 4 5 2 1 H A R VA R D P I L G R I M H E A LT H C A R E H T T P : / / W W W. P RO V I D E R L O O K U P O N L I N E . C O M / H A R VA R D P I L G R I M / P O 7 / S E A RC H . A S P X 1 - 8 8 8 - 3 3 3 - 4 7 4 2 T U F T S H E A LT H P L A N H T T P : / / W W W. T U F T S H E A LT H P L A N . C O M / PA R T N E R S 1 - 8 0 0 - 8 4 3 - 1 0 0 8 N E I G H B O R H O O D H E A LT H P L A N H T T P : / / N H P. S P E C T R A L O G I X . C O M / PA R T N E R S . A S P 1 - 8 0 0 - 4 6 2 - 5 4 4 9

DID YOU KNOW?

Prescription drug coverage is provided by Express Scripts (formerly called Medco) based on an Open

Formulary — a list of covered prescriptions. You can save by filling maintenance prescriptions by mail order and receive a three month's supply for only a two month's co-pay. Learn more at:

https://www.express-scripts.com or contact Express Scripts at 1-800-711-4541.

Co-pays for prescription drugs will remain the same in 2014.

The IRS allows you to submit health care expenses incurred through the following March 15 to your

Health Care Flexible Spending Account. This gives you an extra 2.5 months to build up expenses that can be reimbursed using last year’s account balance. Using a Health Care Flexible Spending Account is a tax-smart way to pay for many qualified expenses not covered by any medical, dental, hearing, or vision coverage. Submit your FSA expenses the easy, online way with FSA Express. Please make sure to submit your expenses by March 31.

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IMPORTANT INFORMATION ABOUT YOUR HEALTH COVERAGE

You have 30 days from the date you first become eligible or the date you experience a Qualified Change of Status (described below) to enroll or change health coverage. Internal Revenue Code regulations prohibit us from accepting enrollments outside of this 30-day period, except during Fall open enrollment.

QUALIFIED CHANGE OF STATUS

You may change your Medical, Dental, or Vision coverage level or your Health Care and/or Dependent Care Account participation when you experience a qualified change of status. This change must be requested within 30 days of the event and must be consistent with the event. For example:

Marriage or divorce

Addition of a dependent through birth, adoption, or change in custody

Death of spouse or dependent

Gain or loss of eligibility for Medicaid, Medicare, or other group coverage

You or your spouse change from benefits-eligible to benefits-ineligible status, or vice versa

Your spouse’s employment ends

You move out of your medical plan’s coverage area

Your child under age 26 gains or loses eligibility for coverage on a health plan

COVERAGE FOR YOUR ELIGIBLE CHILDREN

Your children are eligible for health coverage on your plans up to age 26. If your child under age 26 previously lost coverage, you may enroll your child on your health plans during open enrollment, to be effective the following January 1.

Y O U R C O B R A R I G H T S

When you or your covered dependents are no longer eligible for coverage under your Partners medical, dental, vision plan, or health care flexible spending account, you or your covered dependents may be eligible to continue this coverage as provided by the Consolidated Omnibus Budget Reconciliation Act (COBRA). A description of your COBRA rights is included in your annual open enrollment packet.

B E N E F I T QU E S T I O N S ?

BWH Residents should email BWHprofstaffbene@partners.org or call 617-724-9357. MGH Residents (based on the last names) should contact:

A-G: Susan Frain (sfrain@partners.org, 617-726-9264) H-O: Linda Gulla (lgulla@partners.org, 617-726-9266)

P-Z: Virginia Rosales CEBS (vrosales@partners.org, 617-724-9356)

H I PA A P RO V I S I O N

If You Declined Medical Coverage Because You Have Coverage Elsewhere

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may have the opportunity to enroll yourself and your eligible dependents for medical coverage during the year if you previously declined coverage as follows:

You and/or your dependents have coverage from another source (such as your spouse’s medical plan or

COBRA coverage) and you lose that coverage; or

You acquire a dependent through marriage, birth, adoption, or placement for adoption.

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References

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