2015 Medical and Dental Plan Comparison Chart

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Benefits for Professional Staff

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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

Medical Out-of-Pocket Maximum (individual/family)1 Pre-Admission Certification

Primary Care Physician Maximum Lifetime Benefit

i

nPatient

M

edicaland

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

ealtHand

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 – CVS/caremark at participating pharmacies1, 4 60-Day co-pays: $20/$60/$100 90-Day Maintenance Choice 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%

$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 (visits 1-15); $15 co-pay (visits 16+); 100% 80% after deductible

$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 Supply $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 (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)

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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 Preferred Network BCBS Plan Network Out-of-Network

PARTNERS VALUE

G

eneral

P

rovisions

i

nPatient

M

edicaland

s

urGical

s

i

nPatient

M

ental

H

ealtHand

s

ubstance

a

buse

s

o

utPatient

c

overed

s

Speech Therapy

M

aternity

c

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%

$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

$500/$1,000 75% Required Recommended Unlimited $250 after deductible 75% after deductible 75% after deductible Not covered 80% after deductible $35 $50 co-pay; 100% $0 co-pay; 100% $0 co-pay; 100% $50 co-pay; 100%

$150 co-pay; 100%

$35 co-pay; 100% 80%

100% $50 co-pay

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

$250 co-pay; 80% 100% 100%

$50 co-pay (visits 1-15); $15 co-pay (visits 16+); 100% 75% after deductible

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Partners Preferred Network HPHC Plan Network

HARVARD PILGRIM HEALTH CARE

G

eneral

P

rovisions

i

nPatient

M

edicaland

s

urGical

s

i

nPatient

M

ental

H

ealtHand

s

ubstance

a

buse

s

o

utPatient

c

overed

s

Speech Therapy

M

aternity

c

o

tHer

s

ervices

Not covered 100% 100%

$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%

Not covered 100%

$150 co-pay; 100%

$15 co-pay; 100% 80%

100% $40 co-pay

100% (100 Days per year maximum) 100%

100%

$40 co-pay (visits 1-15); $15 co-pay (visits 16+); 100% $15 co-pay (up to 12 visits per year)

Not covered (limited services only)

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TUFTS HEALTH PLAN

Partners Preferred Network Tufts Plan Network

G

eneral

P

rovisions

i

nPatient

M

edicaland

s

urGical

s

i

nPatient

M

ental

H

ealtHand

s

ubstance

a

buse

s

o

utPatient

c

overed

s

Speech Therapy

M

aternity

c

o

tHer

s

ervices

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%

$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%

Not covered 100%

$150 co-pay; 100%

$15 co-pay; 100% 80% 100% $40 co-pay

100%

100% with authorization 100%

$40 co-pay (visits 1-15); $15 co-pay (visits 16+); 100% with authorization $15 co-pay; 100% (up to 12 visits per year)

Not covered (limited services only)

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Dental Services

Basic Dental

Major Dental

Calendar-Year Maximum $1,000 per person $2,000 per person

(excluding orthodontia)

Diagnostic/Preventive Services

Complete initial exam and charting — once Periodic oral exams — 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

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 ages 16 up to age 19 who have had a recent cavity and are at risk for decay.

Periodontal cleaning — Once every three months following active periodontal treatment, not to be combined with preventive cleanings.

Minor Restorative

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 primary 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 — one surgical procedure per quadrant, in 36 months

Endodontics

Root canal therapy — once per tooth Vital pulpotomy — limited to deciduous teeth

Prosthetic Maintenance

Bridge or denture repairs — once within 12 months, same repair Rebase of dentures — once every 36 months

Recementing crowns and onlays — once every 12 months per tooth

Emergency Dental Care

Minor treatment for pain relief — three occurrences in 12 months

General Anesthesia

and IV sedation are allowed with covered surgery for impacted wisdom teeth.

Major Restorative

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

Orthodontia

Active orthodontic treatment

Lifetime orthodontia maximum

100% Coverage

No Deductible

50% Coverage

after plan deductible

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MEDICAL PLAN HIGHLIGHTS FOR

2015

n 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.

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

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

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

the same in the Partners Preferred and Plan Networks.

n 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.

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

admitted.

n 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.

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

following websites:

BLUE CROSS BLUE SHIELD (for Partners Plus, Partners Value)

WWW.BLUECROSSMA.COM/PARTNERS 1-888-211-4521

HARVARD PILGRIM HEALTH CARE

HTTP://WWW.PROVIDERLOOKUPONLINE.COM/HARVARDPILGRIM/PO7/SEARCH.ASPX 1-888-333-4742

TUFTS HEALTH PLAN

HTTP://WWW.TUFTSHEALTHPLAN.COM/PARTNERS 1-800-843-1008

DID YOU KNOW?

n Prescription drug coverage is provided by CVS/caremark based on an Open Formulary — a list of covered

prescriptions. You can save by filling maintenance prescriptions through Maintenance Choice (mail order or CVS/pharmacy pick up) and receive a three month supply for only a two month co-pay.

An out-of-pocket maximum applies to the prescription drug plan, based on your salary and medical plan

coverage level as of January 1, 2015:

Under $50,000: $250 individual coverage/$500 for all other coverage levels

$50,000 to $100,000: $800 individual coverage/$1,600 for all other coverage levels

Above $100,000: $1,600 individual coverage/$4,000 for all other coverage levels

If you enroll in Partners Value, you will pay twice these amounts before you reach the out-of-pocket maximum.

n Co-pays for prescription drugs will remain the same in 2015.

n 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:

n Marriage or divorce

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

n Death of spouse or dependent

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

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

n Your spouse’s employment ends

n You move out of your medical plan’s coverage area

n 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.

YOUR COBRA RIGHTS

When you or your covered dependents are no longer eligible for coverage under your MGPO 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. For further information,

or to obtain a copy of the COBRA notice at other times of the year, please contact the Professional Staff Benefits Office:

If your last name begins with A to G, call: Susan Frain at [email protected] or 617-726-9264 If your last name begins with H to O, call: Linda Gulla at [email protected] or 617-726-9266

If your last name begins with P to Z, call: Virginia Rosales, CEBS at [email protected] or 617-724-9356

HIPAA PROVISION

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:

n 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

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