* Plan is also available with a prescription deductible of $250 individual/$500 family and $20/$75/$100 copayments. HMO products offered by Tufts Associated Health Maintenance Organization, Inc.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager.
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Level
Office Visit Copay
ER Copay Hospital Copay High-Tech Imaging Coinsurance Member
Medical Deductible Individual/
Family
Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/Family Pediatric Dental: One child/Two or more children
Pharmacy Benefit
Summary RelativityPricing Routine Physical Exam Non-Routine Office Visit HMO Value 250 PLATINUM $0 $15 $100 $250 $100 N/A No Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 26% Basic 25 PLATINUM $0 $25 $125 $500 $100 N/A No Medical: $2,500/$5,000 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 17% Advantage 500 PLATINUM $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full
after Deductible N/A $500/$1,000
Medical: $1,000/$2,000 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 8% Advantage 1000 GOLD $0 $20 Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full N/A $1,000/$2,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 (baseline)1 Advantage 1500* GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full
after Deductible N/A $1,500/$3,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -8% Advantage 2000 GOLD $0 $20 Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full N/A $2,000/$4,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -10% Advantage HMO 2000 (80%) SILVER
$0 $30 20% coinsuranceDeductible then 20% coinsuranceDeductible then 20% coinsuranceDeductible then 20% $2,000/$4,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000
$20/$75/$100
PPO deductibles and out-of-pocket maximums track separately for in-network and out-of-network services.
PPO products offered by Tufts Associated Health Maintenance Organization, Inc., Tufts Insurance Company, or Tufts Benefit Administrators, Inc., all Tufts Health Plan companies.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Level
Office Visit Copay
ER Copay
Hospital Copay
High-Tech
Imaging CoinsuranceMember Medical Deductible Individual/Family
Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/Family Pediatric Dental: One child/Two or more children
Pharmacy Benefit
Summary RelativityPricing Routine Physical Exam Non-Routine Office Visit Surgical Day Care Copay Inpatient Copay
PPO In-network Out-of-network
Value PLATINUM $0 $15 $100 $250 $250 $100 20% out-of-network $500/$1,000 Deductible Out-of-network Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,950/$7,900 $15/$30/$50 Mail: $30/$60/$150 59% Basic 25 PLATINUM $0 $25 $125 $500 $500 $100 out-of-network20% $750/$1,500 Deductible Out-of-network Medical: $2,500/$5,000 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,500/$7,000 Mail: $30/$60/$150$15/$30/$50 46% Advantage 500 PLATINUM
$0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% out-of-network $500/$1,000 Deductible Medical: $1,000/$2,000 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $2,000/$4,000 Mail: $30/$60/$150$15/$30/$50 38% Advantage 1000 GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% out-of-network $1,000/$2,000 Deductible Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,950/$7,900 $15/$30/$50 Mail: $30/$60/$150 27% Advantage 1500 GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% out-of-network $1,500/$3,000 Deductible Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,950/$7,900 Mail: $30/$60/$150$15/$30/$50 12% Advantage 2000 GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% out-of-network $2,000/$4,000 Deductible Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,950/$7,900 Mail: $30/$60/$150$15/$30/$50 8% Advantage PPO 2000 (80/60) SILVER $0 $30 Deductible then 20% coinsurance in-network Deductible then 20% coinsurance in-network Deductible then 20% coinsurance in-network 20% in-network 40% out-of-network $2,000/$4,000 Deductible Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 Medical: $3,950/$7,900 $20/$75/$100 Mail: $40/$150/$300 -6%
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Tier
Office Visit Copay
ER Copay
Inpatient Hospital
Copay
Day Surgery Center High-Tech Imaging Diagnostic Tests
Member Coinsurance Medical Deductible Individual/ Family Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/Family Pediatric Dental: One child/Two or more children Pharmacy Retail Copays Pricing Relativity PCP Specialist Freestanding Outpatient Surgery Center Hospital Freestanding Imaging Center Hospital or Other Provider Any Non Hospital Provider Outpatient Hospital
YOUR CHOICE HMO — A Tiered Provider Network Option
Your Choice HMO 3-Tier Option 9 - GOLD
Tier 1 $25 $35 $200 Deductible then $500 $500 Deductible then $500 $100 Deductible then $100 Covered in full Deductible then covered in full N/A $250/$500 Medical: $3,950/$7,900 Pharmacy: $1,400/$2,800 Pediatric Dental: $1,000/$2,000 $20* -7% Tier 2 $35 $45 $200 Deductible then $750 Deductible then $750 Deductible then $350 Deductible then covered in full N/A $1,000/$2,000 $35 Tier
3 $45 $55 $200 then $1,000Deductible then $1,000Deductible Deductible then $750
Deductible then covered
in full N/A $2,000/$4,000 $50
Your Choice HMO 3-Tier Option 10 - GOLD
Tier 1 $25 $35 $150 Deductible then covered in full $250 Deductible then covered in full $150 Deductible then covered in full Covered in full Deductible then covered in full N/A $500/$1,000 Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15* -4% Tier 2 $35 $50 $150 Deductible then covered in full Deductible then covered in full Deductible then covered in full Deductible then covered in full N/A $1,000/$2,000 $30 Tier 3 $50 $75 $150 Deductible then covered in full Deductible then covered in full Deductible then covered in full Deductible then covered in full N/A $2,000/$4,000 $50
* Mail Order Pharmacy: 90-day supply is available at the 60-day supply copayment for Tier 1 and Tier 2 medications. Tier 3 medications require the 90-day supply copayment.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager.
Tier
Office Visit Copay
ER Copay
Inpatient Hospital
Copay
Day Surgery Center High-Tech Imaging Diagnostic Tests
Member Coinsurance Medical Deductible Individual/Family Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/ Family Pediatric Dental: One
child/Two or more children Pharmacy Retail Copays Pricing Relativity PCP Specialist Freestanding Outpatient
Surgery Center Hospital
Freestanding Imaging Center Hospital or Other Provider Any Non Hospital Provider Outpatient Hospital
YOUR CHOICE HMO — A Tiered Provider Network Option
Your Choice HMO 2-Tier Option 8 - GOLD
Tier 1 $25 $40 $200 Deductible then $500
$250 Deductible then $500 $150 Deductible then $200 Covered in full Deductible then covered in full N/A $750/$1,500 Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15* -4% Tier 2 $50 $70 $200 Deductible then $1,000 Deductible then $1,000 Deductible then $450 Deductible then covered in full N/A $35 Tier 3 $50
Your Choice HMO 2-Tier Option 9 - GOLD
Tier 1 $25 $40 $150 then covered Deductible in full $250 Deductible then covered in full $150 Deductible then covered in full Covered in full Deductible then covered in full N/A $1,000/$2,000 Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15* -4% Tier 2 $50 $70 $150 then $1,000Deductible Deductible then
$1,000 Deductible then $450 Deductible then covered in full N/A $30 Tier 3 $50
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
* Mail Order Pharmacy: 90-day supply is available at the 60-day supply copayment for Tier 1 and Tier 2 medications. Tier 3 medications require the 90-day supply copayment.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
PPO products offered by Tufts Associated Health Maintenance Organization, Inc., Tufts Insurance Company, or Tufts Benefit Administrators, Inc., all Tufts Health Plan companies. PPO/Advantage products offered by Tufts Insurance Company, or Tufts Benefit Administrators, Inc., both Tufts Health Plan companies.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager.
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Level
Office Visit Copay
ER Copay Hospital Copay High-Tech Imaging CoinsuranceMember Medical Deductible Individual/Family
Annual Out-of-Pocket Maximum Individual/Family Includes medical, pharmacy
and pediatric dental services
Pharmacy Benefit
Summary RelativityPricing Routine
Physical Exam
Non-Routine Office Visit
ADVANTAGE SAVER (HSA qualified plans that can be coupled with an HSA or HRA)
Advantage HMO Saver
1500 GOLD
$0 in full after Covered Deductible
Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full N/A $1,500/$3,000 $3,125/$6,250
Deductible then $15/$30/$50
Mail: Deductible then $30/$60/$150 -13% Advantage HMO Saver 2000 SILVER $0 Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible Covered in full
after Deductible N/A
$2,000/$4,000
$5,350/$10,700
Deductible then $20/$75/$100
Mail: Deductible then $40/$150/$300 -24% Advantage PPO Saver 1500 GOLD
$0 in full after Covered Deductible
Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full out-of-network20% $1,500/$3,000 $3,125/$6,250
Deductible then $15/$30/$50
Mail: Deductible then $30/$60/$150 10% Advantage PPO Saver 2000 SILVER
$0 in full after Covered Deductible Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% out-of-network $2,000/$4,000 $5,350/$10,700 Deductible then $20/$75/$100
Mail: Deductible then $40/$150/$300
HMO products offered by Tufts Associated Health Maintenance Organization, Inc.
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Level
Office Visit Copay
ER Copay Hospital Copay High-Tech Imaging CoinsuranceMember Medical Deductible Individual/Family
Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/Family Pediatric Dental: One child/Two or more children
Pharmacy Benefit
Summary RelativityPricing Routine Physical Exam Non-Routine Office Visit SELECT NETWORK
Select HMO Basic 25/500 PLATINUM $0 $25 $125 $500 $100 N/A N/A Medical: $2,500/$5,000 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 4% Select Advantage HMO 500 PLATINUM
$0 $20 after DeductibleCovered in full after DeductibleCovered in full after DeductibleCovered in full N/A $500/$1,000 Pharmacy: $2,400/$4,800Medical: $1,000/$2,000 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -4% Select Advantage HMO 1000 GOLD
$0 $20 after DeductibleCovered in full after DeductibleCovered in full after DeductibleCovered in full N/A $1,000/$2,000 Pharmacy: $2,400/$4,800Medical: $2,950/$5,900 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -11% Select Advantage HMO 1500 GOLD
$0 $20 after DeductibleCovered in full after DeductibleCovered in full after DeductibleCovered in full N/A $1,500/$3,000 Pharmacy: $2,400/$4,800Medical: $2,950/$5,900 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -18% Select Advantage HMO 2000 GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full
after Deductible N/A $2,000/$4,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000
$15/$30/$50
Mail: $30/$60/$150 -20%
STEWARD COMMUNITY CHOICE
Copay Plan PLATINUM $0 $15 $150 $250 $100 N/A No Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 6% 1000 GOLD $0 $20 Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full N/A $1,000/$2,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -16% 1500 GOLD $0 $20 Covered in full
after Deductible after DeductibleCovered in full after DeductibleCovered in full N/A $1,500/$3,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 -23% 2000 GOLD $0 $20 Covered in full after Deductible Covered in full after Deductible Covered in full
after Deductible N/A $2,000/$4,000
Medical: $2,950/$5,900 Pharmacy: $2,400/$4,800 Pediatric Dental: $1,000/$2,000
$15/$30/$50
Massachusetts Small Group Plan Design Comparison January 1, 2014
Plan Year or Calendar Year Available for All Plans
Level
Office Visit Copay
ER Copay Hospital Copay High-Tech Imaging CoinsuranceMember Medical Deductible Individual/Family
Annual Out-of-Pocket Maximum Medical: Individual/Family Pharmacy: Individual/Family Pediatric Dental: One child/Two or more children
Pharmacy Benefit
Summary RelativityPricing Routine Physical Exam Non-Routine Office Visit COMMONWEALTH PLANS Commonwealth HMO 25 Version 2 PLATINUM
$0 $40—Specialist$25—PCP $150 $500 $150 N/A N/A
Medical: $1,200/$2,400 Pharmacy: $800/$1,600 Pediatric Dental: $1,000/$2,000 $15/$30/$50 Mail: $30/$60/$150 19% Commonwealth Advantage HMO 500 PLATINUM
$0 $35—Specialist$20—PCP $100 after Deductible
Covered in full after Deductible $100 after Deductible N/A $500/$1,000 Medical: $1,150/$2,300 Pharmacy: $350/$700 Pediatric Dental: $1,000/$2,000 $15/$25/$45 Mail: $30/$50/$135 7% Commonwealth Advantage HMO 400 with Coinsurance GOLD $0 $35—Specialist$20—PCP 30% coinsurance after Deductible 30% coinsurance after Deductible 30% coinsurance after Deductible 35% $400/$800 Pharmacy: $1,000/$2,000Medical: $2,000/$4,000 Pediatric Dental: $1,000/$2,000 $100/$200 Deductible for Tier 2 and Tier 3 then $15/50%/50%
Mail: Deductible
for Tier 2 and Tier 3 then $30/50%/50% -9% Commonwealth Advantage HMO 1000 Version 2 GOLD
$0 $45—Specialist$30—PCP $150 after Deductible
Outpatient: $250 after Deductible Inpatient: $500 after Deductible $200 after Deductible N/A $1,000/$2,000 Medical: $3,000/$6,000 Pharmacy: $2,000/$4,000 Pediatric Dental: $1,000/$2,000 $20/$30/$50 Mail: $40/$60/$150 -4% Commonwealth Advantage HMO 1500 GOLD
$0 $40—Specialist$25—PCP $150 after Deductible $250 after Deductible $150 after Deductible N/A $1,500/$3,000
Medical: $3,000/$6,000 Pharmacy: $2,000/$4,000 Pediatric Dental: $1,000/$2,000 $15/$25/$50 Mail: $30/$50/$150 -10% Commonwealth Advantage HMO 2000 Version 4 SILVER
$0 $60—Specialist$35—PCP $350 after Deductible $1,000 after Deductible $400 after Deductible N/A $2,000/$4,000 Pharmacy: $1,400/$2,800Medical: $3,950/$7,900 Pediatric Dental: $1,000/$2,000
$25/$50/$75
Mail: $50/$100/$225 -33%
Mandatory mail order applies for all maintenance medications on Commonwealth plans.
Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager.
