STOP LOSS RFP FY 2018.pdf

Town of Canton

REQUEST FOR PROPOSALS

Item Submission Deadline

Medical Stop-Loss Coverage Wednesday, June 7, 2017 at Noon

INTRODUCTION

The Town of Canton is requesting proposals for stop-loss coverage for the Town’s two health plans with Blue Cross Blue Shield of Massachusetts for the plan year July 1, 2017 to June 30, 2018. The two health plans include HMO Network Blue New England and Blue Care Elect PPO. Attached are summaries of benefits and coverages.

Proposals are requested for specific stop loss insurance according to the deductible levels outlined in the Stop Loss Proposal Request. Proposals should be based on providing specific reinsurance for claims incurred in twelve months and paid in up to twenty-four months, as outlined in the Stop Loss Proposal Request.

Specifications regarding our health insurance plans, current stop loss levels, and rates and specific deductibles to be quoted can be found on the Stop Loss Proposal Request.

Also, attached is an age/gender census, a large claims report and benefit summaries for the two plans.

Respondents must have the capability to track and file claims. Also, references from current Massachusetts municipal accounts must be provided.

Sealed proposals should be marked “Town of Canton Stop Loss Reinsurance Proposals”, and submitted to the Department of Finance no later than noon on Wednesday, June 7, 2017.

The Department of Finance is located at Memorial Hall, 801 Washington Street, Canton, MA 02021.

The Town of Canton reserves the right to accept or reject any or all proposals in the best interest of the Town of Canton. The Town of Canton reserves the right to reject any response that does not meet the minimum criteria, or does not completely answer all questions posed in this "Request For Proposals." The Town of Canton reserves the right to independently verify the accuracy of information supplied in the RFP response. The Town of Canton reserves the right to reject any RFP response that is not submitted in the requested format or not properly signed.

Completed proposals must include:

* Proposal Pricing Form - returned separately

* RFP Questionnaire

* Sample Policy

* Tax Compliance Form & Non-Collusion Certificate

MINIMUM CRITERIA

Responses to this Request for Proposal must meet all of the Minimum Criteria listed below in order for the bid to be considered.

• Proposer must respond to all questions and requests on the “RFP Questionnaire” of this Request for Proposal and submit all items, data, information, and reports requested.

• The “Proposal Pricing Form” must be returned to the Town of Canton in a separate envelope and marked as specified in the Introduction. All supporting documentation should be forwarded under a separate cover.

• Reinsurance policy must provide coverage over the Town of Canton's two health benefits plans administered by Blue Cross Blue Shield of Massachusetts (HMO Network Blue New England and Blue Care Elect PPO.)

• The reinsurance carrier must have accepted Blue Cross Blue Shield as an administrator. The reinsurance carrier must currently be a reinsurer over this administrator or the broker and/or independent stop loss administrator must have three or more years experience tracking claims over this plan administrator.

• The proposal prices must be all-inclusive. That is, the RFP must include costs of reinsuring as required; claims tracking, filing, and reporting; broker commissions;

surplus lines tax in the case of non-admitted carriers; and any other costs which may accrue to proposer or carrier as a result of this reinsurance contract, should it be awarded.

• The reinsurance company must be licensed to do business in Massachusetts.

• Price proposals must be submitted with no contingencies.

RFP QUESTIONNAIRE

You must respond to all questions and requests in this Questionnaire. On a separate sheet of paper, please restate the first question and answer as completely and concisely as possible, then restate second question etc.

1. What is the name and address of the Reinsurance Carrier?

2. What is the name and address of the Company submitting this bid?

3. What is the name and address of the Managing General Underwriter?

4. What is the reinsurance carrier's current A.M. Best Rating?

5. What portion of the policy risk does the reinsurer retain?

6. What portion of the policy risk does the Managing General Underwriter retain?

7. If the MGU cedes any portion of the policy risk to any other person or entity, please identify those persons or other entities, providing the name and address.

8. What was the total stop loss volume written by the reinsurance carrier during the past twelve months?

9. What is the name and description of the firm authorized to do final adjudication of claims for the carrier?

10. What is the name and address of the firm that will issue the reimbursement checks?

11. Describe the process of claims tracking and filing, including the name and address of the firm that will track and file stop loss claims with the carrier or carrier's representative and the years of experience the stop loss tracking and filing firm has had at this activity.

12. Please confirm that:

a. The Policy covers dependents as well as the subscribers who are covered under the plan.

b. There are no exclusions for those plan members who are not actively at work.

c. There are no pre-existing condition exclusions.

RFP QUESTIONNAIRE (continued)

d. There are no waiting periods other than those that may be provided in the plan.

e. Mental and nervous services are covered at the levels mandated by the Commonwealth of Massachusetts.

f. Prescription drugs are covered in accordance with the Plan Document.

13. Please provide an explanation of any unusual competitive provision or restrictions in your proposed contract, such as organ transplant coverage.

14. Please specify the standards the carrier uses to define "experimental procedures."

15. Are any covered individuals identified with different deductibles? If so, please identify who and what the deductibles are.

16. Please provide as references the names of other Massachusetts municipalities you are currently providing stop-loss insurance to. Next to each municipality, please list individuals to contact and their phone numbers.

Signature below confirms that all responses and representations on this Bid Questionnaire are accurate and true.

(Signature of individual(s) authorized to bind broker/agent and carrier) (Date)

(Title) (Name of Company)

TO BE SUBMITTED IN SEPARATE ENVELOPE

PROPOSAL PRICING FORM

PLAN YEAR: JULY 1, 2017 TO JUNE 30, 2018

(Claims incurred in 12 months, paid in 24 months)

Specific Reinsurance

Blue Cross Blue Shield HMO Network Blue New England and Blue Care Elect PPO

Head Counts: Individual: 242 Family: 358

Monthly Monthly Specific Individual Family Level Rate Rate

$125,000

$150,000

$175,000

Maximum Liability __ Includes Deductible or Per Covered Individual ___________________ __ Less Deductible

(Name of Reinsurance Carrier)

(Signature of individual(s) authorized to bind broker/agent and carrier) (Date)

(Title) (Name of Company)

APPENDIX A - UNDERWRITING DATA

SELF-FUNDED PLANS

Monthly Funding Plan Subscribers Rates * I F I F

BCBS Network HMO Blue N.E. 177 292 $827.66 $2,175.41 BCBS Blue Care Elect PPO 65 66 $1,135.21 $2,693.01

* As of July 1, 2017. Rates to remain in effect through June 30, 2018.

IN-FORCE SPECIFIC REINSURANCE COVERAGE

Term Incurred Paid Level Months Months Monthly Rates

I F

$150,000 ** 12 24 $28.01 $88.54

Carrier: Sirius America Insurance Company

** Reflects a corridor of $100,000 along with one member lasered at $275,000

LARGE CLAIMS - see attached exhibit

LARGE CLAIMS REPORT

C l a i m a n t

Member Date of

Birth

Relationship

Diagnosis

Total Claims

7/16-6/17

Policy as of

APR 2017

$150,000

Total Claims

7/15-6/16

Policy as of

APR 2017

$150,000

Total Claims

7/14 - 6/15 Policy as of JUN 2016

$125,000 FINAL

Member

Condition

Retrospective

Score

Member Condition

Prospective Score

Comments

1 06/07/56 EE

Pancreatitis, Ischemic heart disease, Renal TSP 2006,

403.91 hypertensive renal disease w renal failure; ESRD,

585.30 chronic kidney disease, K/Panc. TSP 1/06,

553.21 Incisional hernia, 996.86 Comp. of TSP pancreas, and Kidney 2006. NB HOME

2 02/28/48 EE

340 Multiple sclerosis, 707.04 Decubitus ulcer/ hip, 38.9

Septicemia, 780.39 Convulsions, UTI BCE

3 11/28/53 EE 174.9 breast cancer NB HOME

4 01/02/07 DEP

Trisomy 21, 480.2 & 486 Pneumonia, Down's, congenital heart defect, resp. distress, 327.23 Obstructive sleep apnea; 507 Pneumonitis due to solid/liquid, 770.81Apnea, 769 Resp. distress, Bronchiolitis, 758 Chrosonal anomalies, 519.02 mechanical complication tracheostomy; 708.1 idiopathic urticaria NB HOME

5 04/12/76 EE

746.86 Cardiac congenital disorder, 745 chromosomal

anomalies, 996.01 Pacemaker malfunction, 628.9

Infertility, v238.5, 644.21 Early onset delivery, BREECH $67,058.98 NB HOME

6 10/27/47 SP

203 Multiple myeloma w/out remission, Lenalidomide RX

V58.11 Visit for Antineoplastic Chemo $279,325.07 $432,673.74 $285,950.57 POOR FAIR NB BCBS prime Laser 275K 16/17 YR

7 02/28/61 SP 174.9 breast cancer BCE

8 10/15/63 SP

BMT 10/09, 203 Multiple myeloma , Chemo, V58.81

Fitting and adjustment of vascular catheter. UTI, 486

Acute Bronchitis $69,983.31 $106,099.02 $58,626.56 FAIR GOOD NB HOME Other - $40,998.19

9 5/4/76 SP

642.33 Hypertens. Pregnancy, antepartum, v23.89 High

risk pregnancy,191.1 Mal Neo Brain, 897.0 Traumatic amputation of leg above knee NB HOME

10 7/9/09 DEP

779.3 Feeding problems in newborn, 770.81 Apnea, 758

Chromosonal anomalies, 746.6 Congenital mitral insufficiency, Down's syndrome NB HOME

11 7/25/1930 EE

414.01 Coronary atherosclerosis, cardiac dysrhthmias;

205.10 Chronic Myeloid leukemia WITH remission, 724.2

Lumbago $122,978.73 GOOD GOOD BCE

12 10/1/1928 EE

CORONARY ATHEROSCLEROSIS, MULTIPLE

MYELOMA, 273.1 Monoclonal paraproteinemia, 285.9

Anemia, 250 Diabetes without complications, A FIB

715.36 Osteoarthrosis Local Lower Leg $97,563.40 TERMED TERMED NB HMO DOD 11/19/2014

13 12/26/1968 SP 174.9 Breast cancer, Radiation NB HOME

14 3/24/1973 EE

174.8 Mal Neo of female breast, 999.81 Other infusion

and transfusion reaction. NB HOME

15 8/30/1964 SP

038.9 Unspecified septicemia, 383.9 Unspecified

mastoiditis, 296.3 Depression, 5/12/11 Meningitis & crainiotomy NB HOME

16 1/17/1962 EE 175.9 Mal Neo Male Breast, 193 Mal Neo thyroid gland NB HOME

17 2/17/1956 EE

233 Carcinoma in breast/genitourinary, V58

Radiotherapy NB HOME

18 11/4/1952 EE 185 Prostate cancer BCE

19 6/8/1946 SP

ACUTE KIDNEY FAILURE, 188.9 Bladder cancer, Prostate cancer, 2ND LUNG CANCER, 2ND BRAIN, SPINE $169,724.48 $219,110.01 POOR FAIR NB HOME BCBS PRIME

20 12/28/1975 EE

303.90/291.81 alcohol dependence/withdrawal , PTSD, Head injury, Infectious Disease $75,521.49 $163,197.25 $167,454.62 GOOD VERY GOOD BCE

21 4/29/1957 SP

185 Prostate cancer, 401.9 hypertension; 729.89 musculoskeletal symptoms w/limbs; 327.23 sleep apnea BCE

22 6/20/1989 DEP

Panic disorder, 564.1 Irritable bowel syndrome, 783.21

Loss of weight 557.1 Chronic Vasc Insuff Intest $92,003.25 $76,617.59 GOOD VERY GOOD NB HOME TEMP. DISABLED

23 11/28/1967 EE

202.8 Lymphoma, 288.03 Neutropenia (diseases of white

blood cells), Last chemo 2012 NB HOME

24 8/15/1974 SPS

Cholecystitis, BH, 997.49 other digestive system complications NB HOME

25 3/21/1963 EE

PANCREATITIS, Diabetes, Small bowel obstruction,

553.21 Incarcerated incisional hernia w/out obstruction, septic shock 389 Unsp Septicemia $101,837.82 $210,561.97 $103,340.71 VERY GOOD VERY GOOD NB HOME

26 3/26/1975 SPS

Crohn's disease; 789.06 abdominal pain, epigastric, SACRUM DISORDER $115,627.26 NB HOME

27 11/29/1980 EE

628.9 infertility; 723.0 spinal stenosis of cervical region, TWIN DELIVERY NB HOME

28 12/12/1988 DEP

SEDATIVE HYPNOTIC DEPENDENCE, Infectious

Disease $91,252.85 TERMED TERMED TERMED 12/12/14 26 Yrs BCE

29 12/19/1957 SPS

715.36 osteoarthrosis, lower leg; 721.0 cervical spondylosis w/out myelopathy BCE

30 3/22/1961 SPS 233.0 breast cancer NB HOME

31 11/12/1967 EE

Ischemic heart disease, 996.02 mechanical complication due ot heart valve prosthesis, Aortic valve disorder NB HOME

32 12/25/1950 SPS 154.1; 154.8 rectal cancer BCEP

LARGE CLAIMS REPORT (cont’d.)

C l a i m a n t

Member Date of

Birth

Relationship

Diagnosis

Total Claims

7/16-6/17

Policy as of

APR 2017

$150,000

Total Claims

7/15-6/16

Policy as of

APR 2017

$150,000

Total Claims

7/14 - 6/15 Policy as of JUN 2016

$125,000 FINAL

Member

Condition

Retrospective

Score

Member Condition

Prospective Score

Comments

33 2/18/1943 EE

Iachemic heart disease, Knee replacement, Psoriasis, 715.36/.96 osteoarthrosis, lower leg (unspecified whether Localized/generalized, primary/secondary) BCEP

34 5/2/2013 DEP

749.23 cleft palate w/cleft lip, bilateral, complete; 706.2 sebaceous cyst, Tympanostomy NBNE

35 8/16/1970 SPS

ESRD, peritoneal dialysis since 6/2014, was approved for kidney TSP last year but no mention on new report,

733.42 aseptic necrosis of bone, femur, HEAD 585.6

End Stage Renal Disease $194,359.47 $137,063.51 $107,868.93 FAIR FAIR BCEP MEDICARE PRIME 2/1/17

36 6/11/1940 SPS

Prostate cancer, Heart disease, A Fib, 805.4 fracture of vertebral column, lumbar; v580 ratiotherapy NBNE

37 5/2/1957 SPS 174.8 breast cancer; 512.1 Iatrogenic pneumothorax NBNE

38 8/24/1960 EE 174.4 breast cancer; 288.03 Drug-induced neutropenia NBNE

39 9/11/1957 SPS 174.9 breast cancer; 275.42 hypercalcemia $160,989.94 FAIR GOOD BCEP

40 11/10/1958 EE COLON CANCER, 2ND LIVER CANCER BCE

41 10/3/1963 EE

NONTOXIC UNINODULAR GOITER, Hyperthyroidism, Cellulitis in arm BCE

42 3/6/1956 EE 340.0 MS, 805.02 CL FX Vert. Col w/o cord injury $63,668.74 NB HOME

43 10/27/1949 SPS

ACQ. SPONDYLOLISTHESIS738.4 Acquired spondylolisthesis, 424.1 Aortic valve NB HOME

44 4/9/1977 EE 174.9 & 174.2 Breast Cancer, PLEURAL EFFUSION $132,281.43 NB HOME

45 1/18/2014 DEP

RESPIRATORY DISTRESS, 765.25 Premature 29-30 weeks completed, Home 3/11 TWIN BCE

46 1/18/2014 DEP

765.25 Premature 29-30 weeks completed, Home 3/18, TWIN TWIN BCE

47 8/28/1961 SPS

724.02 Lumbago, 288.6 Leukocytosis, V57.89 REHAB, Spinal stenosis BCEP

48 3/23/1953 EE

340 Multiple sclerosis, 998.32 Disruption of operation wound, V57.89 REHAB $31,584.07 TERMED TERMED DECEASED 10/20/15 NB HOME

49 10/3/1944 EE

ATHEROSCLEROSIS, 3rd degree burns, skin loss, EAR

414.01 Cor Atherosclerosis Native Cor Art $102,974.72 BCE

50 5/20/1969 EE MULTIPLE SCLEROSIS $65,473.32 $64,184.52 VERY GOOD VERY GOOD NB HOME

51 4/22/1994 DEP OPOIOD DEPENDENCE, BEHAVIORAL HEALTH $99,580.55 BCEP

52 7/16/1966 SPS ACUTE NECROSIS OF LIVER $144,175.80 NB HOME

53 11/30/1992 DEP 296.5 BIPOLAR DEPRESSION $35,116.29 BCEP

54 10/3/1970 EE 141.0 TONGUE CANCER $115,519.76 NB HOME Moved $1,288.00 from the 13/14 Yr

55 4/8/1950 SPS 823.32 FX TIBIA W/FIB OPEN $71,519.94 $65,670.86 VERY GOOD VERY GOOD NB HOME

56 7/3/1961 SPS

431 INTRACEREBRAL HEMORRHAGE, REHAB

V57.89 Oth Rehabilitation Care $185,983.49 NB HOME

57 12/20/1988 EE REGIONAL ENTERITIS, INTESTINES $80,286.87 TERMED TERMED TERMED 10/1/15 NB HOME

58 12/5/1952 SPS MORBID OBESITY $71,973.39

NB HOME

OLD # 9837493

NEW # 960880011

59 11/4/1950 EE 2ND CANCER PERITONEUM $71,363.86 TERMED TERMED BCEP DECEASED DOD 4/16/2015

60 3/10/1956 SPS FX FIBULA W/TIBIA $78,076.48 NB HOME

61 12/26/2014 DEP

PERINATAL CHRONIC RESPIRATORY DISTRESS

V30.01 Single Liveborn W/C Section $344,778.89 NB HOME

62 3/11/1954 EE

CARDIOMYOPATHIES 427.89 Oth Cardiac

Dysrhythmias $93,492.05 NB HOME

63 4/24/1950 SPS

MANTLE CELL LYMPHOMA, INFECTIOUS DISEASE,

POSTMENOPAUSAL BLEEDING 627.1 $96,326.54 $88,615.53 TERMED TERMED TERMED 1/5/16 BCEP

64 1/27/1934 EE DISSECT THORACIC AORTA, OSTEOARTHROSIS LEG $81,924.68 $69,921.64 BCEP

65 5/21/1965 EE CERVICAL SPONDYLOSIS W/MYELOPATHY $93,499.62 VERY GOOD VERY GOOD NB HOME

66 4/24/1957 SPS

ALCOHOL CIRRHOSIS LIVER 820.21 FX

Intertrochanteric Femur Closed $249,317.50 POOR POOR NB HOME

67 2/15/1959 EE ATHEROSCLEROSIS LIMB $3,859.14 VERY GOOD VERY GOOD NB HOME LG CREDITS 2/16

68 1/27/1992 DEP BH, OPIOID DEPENDENCE Infectious Disease $91,167.34 $177,990.44 EXCELLENT EXCELLENT BCEP Sub's last name

69 5/20/1968 EE BREAST CANCER $92,536.86 GOOD GOOD NB HOME

70 11/22/1954 SPS 152.1 Malig Neoplasm Jejunum $96,658.80 $148,753.89 GOOD GOOD NB HOME

71 4/29/1985 EE FEMALE INFERTILITY $86,979.31 VERY GOOD VERY GOOD NB HOME

72 9/9/1953 SPS INCISIONAL HERNIA W/ OBST $97,894.86 GOOD VERY GOOD BCEP

73 4/15/1950 EE VENTRICULAR FIBRILLATION $151,973.64 FAIR GOOD NB HOME Termed 5/1/2017 MEDEX

74 7/20/2016 DEP

COARCTATION AORTA, ENDOCARDIAL CUSHION

DEFECT $517,727.87

POOR

POOR NB HOME

75 1/22/1972 EE HEPATIC FAILURE, ASCITES $87,228.48 TERMED TERMED NB HOME Termed 9/30/2016

76 9/26/1959 SPS GB CHOLESTEROLOSIS $104,525.09 VERY GOOD VERY GOOD BCEP

77 5/28/1955 SPS SUBENDOCARDIAL INFARCTION, INITIAL $98,451.90 EXCELLENT VERY GOOD HMO NE TO NB

78 1/9/1977 EE BREAST CANCER $103,908.80 TERMED TERMED TERMED 1/1/2017 HMO NE

79 4/24/1957 SPS

ALCOHOLIC CIRRHOSIS OF LIVER, TRAUMATIC FX

LOWER LEG $121,089.35

POOR

POOR HMO NE

80 5/2/1951 SPS SEVERE MALNUTRITION $284,401.89 TERMED TERMED DECEASED 1/18/17 HMO NE

81 10/17/1972 SPS CHRONIC PAIN $109,632.01 GOOD VERY GOOD HMO NE

82 8/13/1971 EE BREAST CANCER $84,324.54 VERY GOOD VERY GOOD HMO NE

SUBSCRIBER AGE/GENDER CENSUS

Name of Plan: Blue Care Elect PPO

Individual Family

Age Group Male Female Male Female

<25 1 1 1 0

25-29 0 10 0 0

30-39 2 7 3 7

40-44 1 2 3 3

45-49 3 0 3 3

50-54 1 1 3 8

55-59 2 2 7 4

60-64 1 11 5 10

65+ 7 13 2 4

TOTAL 18 47 27 39

SUBSCRIBER AGE/GENDER CENSUS

Name of Plan: Blue Cross Blue Shield HMO NETWORK BLUE

Individual Family

Age Group Male Female Male Female

<25 3 2 0 0

25-29 8 17 3 5

30-39 18 29 20 35

40-44 5 14 18 18

45-49 3 8 32 31

50-54 6 8 35 20

55-59 10 16 15 21

60-64 3 21 8 21

65+ 1 5 5 5

TOTAL 57 120 136 156

As of 4/25/17.

TAX COMPLIANCE

MASS. GENERAL LAWS, CH. 62C, S. 49a (b)

I hereby certify that I have complied with all laws of the Commonwealth of

Massachusetts relating to taxes.

Signed under the pains and penalties of perjury.

(Proposer's Name)

By:___________________________

Date: _______________________

NON-COLLUSION CERTIFICATE

The undersigned certifies under penalties of perjury that this proposal has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word "person" shall mean any natural person, business, partnership corporation, union committee, club, or other organization, entity, or group of individuals.

(Proposer's Name)

By:___________________________

Date: _______________________

STOP LOSS PROPOSAL REQUEST

GENERAL INFORMATION

1) Name of Prospective Insured: TOWN OF CANTON

2) Address (city, state, zip code): CANTON, MA 02021

3) Nature of Business: MUNICIPALITY

4) Effective date of coverage: July 1, 2017

5) Name of Administrator(s): COOK & COMPANY

Plan(s): HMO NETWORK BLUE NEW ENGLAND AND

BLUE CARE ELECT PPO

6) In-Force Contract: Eff. Date: July 1, 2016 Carrier: Sirius American Insurance Company

Spec. Level: $150,000 Life Max.: Unlimited

Ind. Rate: $28.01 Fam. Rate: $88.54 Laser(s): One member at $275,000

Type of Contract: 12/24 Aggregate: ( ) yes (√) no

Specific Coverage

1) Deductible: (√) $125,000 (√ ) $150,000 (√ ) $175,000

2) Maximum Indemnity: ( ) $1 Million ( ) $2 Million (√ ) Other: Unlimited

3) Benefits to be covered: (√) Medical ( ) Other: ____________________

4) Type of Contract: ( ) 12/12 ( ) 12/18 ( ) Other: 24

( ) 12/15 (√ ) 12/24

Aggregate Coverage ( ) yes (√ ) no

1) Attachment Point: ( ) 125% ( ) Other: __________

2) Maximum Indemnity: ( ) _______________ ( ) ________________

3) Benefits to be covered: ( ) Medical ( ) Other: ___________

4) Type of Contract: ( ) 12/12 ( ) 12/15 ( ) Other: ________ ( ) Paid

Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services Coverage Period: on or after 07/01/2017 Blue Care Elect $250 Deductible Town of Canton Coverage for: Individual and Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see http://www.town.canton.ma.us/608/Medical-

Benefits. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.bluecrossma.com/sbcglossary or call 1-800-782-3675 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

$250 member / $750 family.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network preventive and prenatal care, most office visits, mental health visits, therapy visits, durable medical equipment, prescription drugs.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

$2,000 member / $4,000 family.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.bluecrossma.com/findadoct or or call 1-800-821-1388 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

http://www.town.canton.ma.us/608/Medical-Benefits http://www.town.canton.ma.us/608/Medical-Benefits http://www.bluecrossma.com/sbcglossary https://www.healthcare.gov/coverage/preventive-care-benefits/ http://www.bluecrossma.com/findadoctor

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information In-Network

(You will pay the least)

Out-of-Network (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $20 / visit 20% coinsurance

Deductible applies first for out-of-network; family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, nurse practitioner, physician assistant, optometrist, licensed dietitian nutritionist, multi-specialty provider group

Specialist visit $35 / visit; $20 / chiropractor visit

20% coinsurance;

20% coinsurance / chiropractor visit

Deductible applies first for out-of-network

Preventive care/screening/immunization No charge 20% coinsurance

Deductible applies first for out-of-network; limited to age-based schedule and / or frequency. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first

Imaging (CT/PET scans, MRIs) $100 20% coinsurance Deductible applies first; copayment applies per category of test / day; pre-authorization may be required

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information In-Network

(You will pay the least)

Out-of-Network (You will pay the most)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.bluecrossma.com/med ications

Generic drugs $10 / retail supply or

$20 / mail service supply

Not covered

Up to 30-day retail (90-day mail service) supply; cost share may be waived for certain covered drugs and supplies; pre-authorization required for certain drugs

Preferred brand drugs $25 / retail supply or

$50 / mail service supply

Not covered

Non-preferred brand drugs $50 / retail supply or $100 / mail service supply Not covered

Specialty drugs Applicable cost share (generic, preferred, non-preferred) Not covered

When obtained from a designated specialty pharmacy; pre-authorization required for certain drugs

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) $150 / admission 20% coinsurance Deductible applies first

Physician/surgeon fees No charge 20% coinsurance Deductible applies first

If you need immediate medical attention

Emergency room care $100 / visit $100 / visit Deducible applies first; copayment waived if admitted or for observation stay

Emergency medical transportation No charge No charge Deductible applies first

Urgent care $35 / visit 20% coinsurance Deductible applies first for out-of-network

If you have a hospital stay

Facility fee (e.g., hospital room) $300 / admission 20% coinsurance Deductible applies first; pre-authorization required

Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre-authorization required

If you need mental health, behavioral health, or substance abuse services

Outpatient services $20 / visit 20% coinsurance Deductible applies first for out-of-network; pre-authorization required for certain services

Inpatient services $300 / admission 20% coinsurance Deductible applies first; pre-authorization required for certain services http://www.bluecrossma.com/medications

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information In-Network

(You will pay the least)

Out-of-Network (You will pay the most)

If you are pregnant

Office visits No charge 20% coinsurance Deductible applies first except for in-network prenatal care; cost sharing does not apply for in-network preventive services; maternity care may include tests and services described elsewhere in the SBC (i.e.

ultrasound)

Childbirth/delivery professional services No charge 20% coinsurance

Childbirth/delivery facility services $300 / admission 20% coinsurance

If you need help recovering or have other special health needs

Home health care No charge 20% coinsurance Deductible applies first; pre-authorization required

Rehabilitation services $20 / visit 20% coinsurance

Deductible applies first for out-of-network; limited to 60 visits per calendar year (other than for autism, home health care, and speech therapy)

Habilitation services $20 / visit 20% coinsurance

Deductible applies first for out-of-network; rehabilitation therapy coverage limits apply; cost share and coverage limits waived for early intervention services for eligible children

Skilled nursing care No charge 20% coinsurance Deductible applies first; limited to 100 days per calendar year; pre-authorization required

Durable medical equipment No charge 30% coinsurance Deductible applies first for out-of-network; 20% coinsurance out-of-network for one breast pump per birth

Hospice services No charge 20% coinsurance Deductible applies first; pre-authorization required for certain services

Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information In-Network

(You will pay the least)

Out-of-Network (You will pay the most)

If your child needs dental or eye care

Children’s eye exam No charge 20% coinsurance Deductible applies first for out-of-network; limited to one exam every 24 months

Children’s glasses Not covered Not covered None

Children’s dental check-up

No charge for members with a cleft palate / cleft lip condition

20% coinsurance for members with a cleft palate / cleft lip condition

Limited to members under age 18;

deductible applies first for out-of-network

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture

Children's glasses

Cosmetic surgery

Dental care (Adult)

Long-term care

Private-duty nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Bariatric surgery

Chiropractic care

Hearing aids ($2,000 per ear every 36 months for members age 21 or younger)

Infertility treatment

Non-emergency care when traveling outside the U.S.

Routine eye care - adult (one exam every 24 months)

Routine foot care (only for patients with systemic circulatory disease)

Weight loss programs ($150 per calendar year per policy)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform and the U.S. Department of Health and Human Services at 1-877-267-2323 x6156 or www.cciio.cms.gov. Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact the Massachusetts Division of Insurance at 1-877-563-4467 or www.mass.gov/doi. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

For more information about possibly buying individual coverage through a state exchange, you can contact your state’s marketplace, if applicable. If you are a Massachusetts resident, contact the Massachusetts Health Connector by visiting www.mahealthconnector.org. For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.)

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the Member Service number listed on your ID card or contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.)

Does this plan provide Minimum Essential Coverage? [Yes] If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? [Yes] If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––– http://www.dol.gov/ebsa/healthreform http://www.cciio.cms.gov/ http://www.mass.gov/doi http://www.healthcare.gov/ http://www.mahealthconnector.org/

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe's Type 2 Diabetes Jacquie’s Simple Fracture (9 months of in-network prenatal care and a hospital delivery)

(a year of routine in-network care of a well-controlled condition)

(in-network emergency room visit and follow-up care)

■The plan’s overall deductible $250 ■The plan’s overall deductible $250 ■The plan’s overall deductible $250

■Delivery fee copay $0 ■Specialist visit copay $35 ■Specialist visit copay $35

■Facility fee copay $300 ■Primary care visit copay $20 ■Emergency room copay $100

■Diagnostic tests copay $0 ■Diagnostic tests copay $0 ■Ambulance services copay $0

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:

Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)

Childbirth/Delivery Professional Services education) Diagnostic test (x-ray)

Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)

Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)

Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,713 Total Example Cost $7,389 Total Example Cost $1,925

In this example, Peg would pay: In this example, Joe would pay: In this example, Jacquie would pay:

Cost Sharing Cost Sharing Cost Sharing

Deductibles $250 Deductibles $134 Deductibles $250

Copayments $316 Copayments $1,190 Copayments $230

Coinsurance $0 Coinsurance $0 Coinsurance $0

What isn't covered What isn't covered

What isn't covered

Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0

The total Peg would pay is $626 The total Joe would pay is $1,379 The total Jacquie would pay is $480

The plan would be responsible for the other costs of these EXAMPLE covered services.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

172311CE (4/17) 75 KP

MCC Compliance

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law.

Nondiscrimination Notice

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

164264M 55-1487 (8/16)

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

Blue Cross Blue Shield of Massachusetts provides:

• Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats).

• Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, call Member Service at the number on your ID card.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at civilrightscoordinator@bcbsma.com.

If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at hhs.gov.

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Translation Resources Proficiency of Language Assistance Services

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的

号码联系会员服务部（TTY 号码：711）。

Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711).

Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711).

Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711).

Arabic/ةيبر:

انتباه: إذا كنت تتحدث اللغة العربية، فتتوفر خدمات المساعدة اللغوية مجاناً بالنسبة لك. اتصل بخدمات الأعضاء على الرقم الموجود على بطاقة هُويتك (جهاز الهاتف

.(711 :”TTY“ النصي للصم والبكم

Mon-Khmer, Cambodian/ខ្មែរ: ការជូនដំណឹង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្់រអ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្

បៅបេើ្័រណ្ណ សរាគា េ់្លៃួនរ្រស់អ្នក (TTY: 711)។

French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré

(TTY : 711).

Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa

(TTY: 711).

Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수

있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.

Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card)

(TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze

(TTY: 711).

Hindi/हिदंी: ध्यान दें: ्दद आप दिनददी बोलत ेिैं, तो भयाषया सिया्तया सेवयाएँ, आप के ललए नन:शुलक उपलब्ध िैं। सदस् सेवयाओ ंको आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल करें (टदी.टदी.वयाई.: 711).

Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે.

તમયારયા આઈડી કયાડ્ડ પર આપેલયા નંબર પર Member Service ને કૉલ કરો (TTY: 711).

Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card (TTY: 711).

Japanese/日本語: お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご

利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください

（TTY: 711）。

German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an

(TTY: 711).

Persian/پارسیان:

شناسایی کارت روی بر مندرج تلفن شمار گیرد. با می قرار شما اختیار در رایگان صورت ب بانی ز کمک شما فارسی است، خدمات بان ز توج: اگر

.(TTY: 711) ید بگیر اعضا« تماس بخش »خدمات با خود

Lao/ພາສາລາວ: ຂໍ ້ ຄວນໃສ່ໃຈ: ຖ້າເຈົ ້ າເວົ ້ າພາສາລາວໄດ້, ມີ ການບໍ ລິ ການຊ່ວຍເຫຼື ອດ້ານພາສາໃຫ້ທ່ານໂດຍ ບໍ່ ເສຍຄ່າ. ໂທ ຫາ ຝ່າຍບໍ ລິ ການສະ ມາ ຊິ ກທີ່ ໝາຍເລກໂທລະສັບຢູ່ໃນບັດຂອງທ່ານ (TTY: 711).

Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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SUMMARY OF BENEFITS

An Association of Independent Blue Cross and Blue Shield Plans

This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law.

Town of Canton

Blue Care Elect $250 Deductible®

Calendar-Year Deductible: $250/$750

Your Choice Your Deductible Your deductible is the amount of money you pay out-of-pocket each calendar year before you can receive coverage for most benefits under this plan. The calendar-year deductible begins on January 1 and ends on December 31 of each year. Your deductible is $250 per member (or $750 per family) for in-network and out-of-network services combined.

When You Choose Preferred Providers You receive the highest level of benefits under your health care plan when you obtain covered services from preferred providers.

These are called your “in-network” benefits. See the charts for your cost share.

Note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you’re still covered, but your benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you.

How to Find a Preferred Provider There are a few ways to find a preferred provider:

• Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card.

• Visit the Blue Cross Blue Shield of Massachusetts website at www.bluecrossma.com/findadoctor

• Call the Physician Selection Service at 1-800-821-1388

When You Choose Non-Preferred Providers You can also obtain covered services from non-preferred providers, but your out-of-pocket costs are higher. These are called your “out-of-network” benefits. See the charts for your cost share.

Payments for out-of-network benefits are based on the Blue Cross Blue Shield allowed charge as defined in your benefit description.

You may be responsible for any difference between the allowed charge and the provider’s actual billed charge (this is in addition to your deductible and/or your coinsurance).

Your Out-of-Pocket Maximum Your out-of-pocket maximum is the most that you could pay during a calendar year for deductible, copayments (including prescription drug copayments), and coinsurance for covered services. Your out-of-pocket maximum is $2,000 per member (or $4,000 per family) for in-network and out-of-network services combined.

Emergency Room Services In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). After meeting your deductible, you pay a copayment for in-network or out-of-network emergency room services. The copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your cost share.

Utilization Review Requirements You must follow the requirements of Utilization Review, including Pre-Admission Review, Pre-Service Approval for certain outpatient services, Concurrent Review and Discharge Planning, and Individual Case Management. For detailed information about Utilization Review, see your benefit description. If you need non-emergency or non-maternity hospitalization, you or someone on your behalf must call the number on your ID card for pre-approval. If you do not notify Blue Cross Blue Shield of Massachusetts and receive pre-approval, your benefits may be reduced or denied.

Dependent Benefits This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your benefit description (and riders, if any) for exact coverage details.

Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network

Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows:

Nothing, no deductible 20% coinsurance after deductible

Routine adult physical exams, including related tests (one per calendar year)

Nothing, no deductible 20% coinsurance after deductible

Routine GYN exams, including related lab tests (one per calendar year)

Nothing, no deductible 20% coinsurance after deductible

Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible

Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger)

All charges beyond the maximum, no deductible

20% coinsurance after deductible and all charges beyond the maximum

Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible

Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible

Outpatient Care Emergency room visits $100 per visit after deductible

(copayment waived if admitted or for an observation stay)

$100 per visit after deductible (copayment waived if admitted or for an observation stay)

Office visits, when performed by:

• A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, licensed dietitian nutritionist, optometrist, multi-specialty provider group, nurse midwife, nurse practitioner, or physician assistant

• Other covered providers

$20 per visit, no deductible

$35 per visit, no deductible

20% coinsurance after deductible

20% coinsurance after deductible

Chiropractors’ office visits $20 per visit, no deductible 20% coinsurance after deductible

Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible

Short-term rehabilitation therapy–physical and occupational (up to 60 visits per calendar year*)

$20 per visit, no deductible 20% coinsurance after deductible

Speech, hearing, and language disorder treatment– speech therapy

$20 per visit, no deductible 20% coinsurance after deductible

Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests)

Nothing after deductible 20% coinsurance after deductible

CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date after deductible

20% coinsurance after deductible

Home health care and hospice services Nothing after deductible 20% coinsurance after deductible

Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible

Durable medical equipment–such as wheelchairs, crutches, hospital beds

Nothing, no deductible 30% coinsurance after deductible**

Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible

Surgery and related anesthesia in an office, when performed by:

• A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, multi-specialty provider group, nurse midwife, nurse practitioner, or physician assistant

• Other covered providers

$20 per visit***, no deductible

$35 per visit***, no deductible

20% coinsurance after deductible

20% coinsurance after deductible

Surgery in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit

$150 per admission after deductible 20% coinsurance after deductible

* No visit limit applies when…