Benefits for Residents
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
ENERALP
ROVISIONSAnnual Deductible (individual/family) The Plan’s Coinsurance
Out-of-Pocket Maximum (individual/family)1
Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit
I
NPATIENTM
EDICAL ANDS
URGICALS
ERVICESPer Admission Co-Pay
Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing
I
NPATIENTM
ENTALH
EALTH ANDS
UBSTANCEA
BUSES
ERVICESInpatient Mental Health and Substance Abuse
O
UTPATIENTC
OVEREDS
ERVICESPrimary 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
ATERNITYC
OVERAGEIn-Hospital (Delivery) Out-of-Hospital (prenatal care)
O
THERS
ERVICESSkilled 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.
PARTNERS VALUE
Partners Preferred Network BCBS Plan Network Out-of-Network
G
ENERALP
ROVISIONSAnnual Deductible (individual/family) The Plan’s Coinsurance
Out-of-Pocket Maximum (individual/family)1
Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit
I
NPATIENTM
EDICAL ANDS
URGICALS
ERVICESPer Admission Co-Pay
Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing
I
NPATIENTM
ENTALH
EALTH ANDS
UBSTANCEA
BUSES
ERVICESInpatient Mental Health and Substance Abuse
O
UTPATIENTC
OVEREDS
ERVICESPrimary 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
ATERNITYC
OVERAGEIn-Hospital (Delivery) Out-of-Hospital (prenatal care)
O
THERS
ERVICESSkilled 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.
Partners Preferred Network
HPHC Plan Network
HARVARD PILGRIM HEALTH CARE
G
ENERALP
ROVISIONSAnnual Deductible (individual/family) The Plan’s Coinsurance
Out-of-Pocket Maximum (individual/family)1
Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit
I
NPATIENTM
EDICAL ANDS
URGICALS
ERVICESPer Admission Co-Pay
Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing
I
NPATIENTM
ENTALH
EALTH ANDS
UBSTANCEA
BUSES
ERVICESInpatient Mental Health and Substance Abuse
O
UTPATIENTC
OVEREDS
ERVICESPrimary 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
ATERNITYC
OVERAGEIn-Hospital (Delivery) Out-of-Hospital (prenatal care)
O
THERS
ERVICESSkilled 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.
TUFTS HEALTH PLAN
Partners Preferred Network
Tufts Plan Network
G
ENERALP
ROVISIONSAnnual Deductible (individual/family) The Plan’s Coinsurance
Out-of-Pocket Maximum (individual/family)1
Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit
I
NPATIENTM
EDICAL ANDS
URGICALS
ERVICESPer Admission Co-Pay
Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing
I
NPATIENTM
ENTALH
EALTH ANDS
UBSTANCEA
BUSES
ERVICESInpatient Mental Health and Substance Abuse
O
UTPATIENTC
OVEREDS
ERVICESPrimary 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
ATERNITYC
OVERAGEIn-Hospital (Delivery) Out-of-Hospital (prenatal care)
O
THERS
ERVICESSkilled 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
NEIGHBORHOOD HEALTH PLAN
Partners Preferred Network
NHP Plan Network
G
ENERALP
ROVISIONSAnnual Deductible (individual/family) The Plan’s Coinsurance
Out-of-Pocket Maximum (individual/family)1
Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit
I
NPATIENTM
EDICAL ANDS
URGICALS
ERVICESPer Admission Co-Pay
Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing
I
NPATIENTM
ENTALH
EALTH ANDS
UBSTANCEA
BUSES
ERVICESInpatient Mental Health and Substance Abuse
O
UTPATIENTC
OVEREDS
ERVICESPrimary 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
ATERNITYC
OVERAGEIn-Hospital (Delivery) Out-of-Hospital (prenatal care)
O
THERS
ERVICESSkilled 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
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
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.
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.