$90 Preferred Brand; $285 Non-Preferred Brand. Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services Coverage Period: on or after 03/01/2019 HMO Blue New England Arbella Insurance Group Coverage for: Individual and Family | Plan Type: HMO Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue … %%EOF your fees from 2019. %%EOF $45 Preferred Brand; $95 Non-Preferred Brand;             Nondiscrimination Notice and Accessibility Services. endstream endobj startxref Brand name drugs, you pay 25%, Additional Benefits, Allowances and Programs, Nondiscrimination Notice and Accessibility Services. Non-preferred generics are covered at 37%, and Preferred and Non-Preferred Brands are covered at 25% of the price or the Health New England negotiated price, whichever is lower. 0 Days 51-100: $0 copay per day, Outpatient Rehabilitation (PA after visit 25)3, Deductible - Applies to Preferred Brand, Member Services 8:00 a.m. - 8:00 p.m. (Monday-Friday), (Oct. 1 - Mar. h�bbd```b``�"���4�tD�� �D�E>�UBؕ`�� �MD����`� ,~���,�樀H�h�R"SAf2�_��ρH� ��@��}&F�(�Pl����y?0 ��� h�b```��lb}B ��ea��`��sswH7h�� ���@Sù5v����u/�ٳ�ܳ�0�Lz���,A�����"���d�1Zy. Brand name drugs, you pay 25% endstream endobj startxref 8You must use Teladoc® service to receive this benefit. 1280 0 obj <>stream Enrollment in Health New England Medicare Advantage depends on contract renewal. Health New England Medicare Advantage is an HMO & HMO-POS plan with a Medicare contract. 1848 0 obj <>stream Days 21-50: $160 copay per day 3Health New England additional benefits include allowances that must be used within the one or two calendar year period, as well as other additional benefits. Compliance h�b```��l"JB ��ea�ap`Hp1(I. 1226 0 obj <> endobj Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services Coverage Period: on or after 07/01/2020 HMO Blue New England Options Deductible v.5 : Wachusett Regional School District Coverage for: Individual and Family | Plan Type: HMO Tiered Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue … Non-Preferred Brand, Specialty Medication, Initial Coverage: Over $3,820 in Drug Costs; 31: 8:00 a.m. - 8:00 p.m. / 7 days a week). Up to $3,820 in Drug Costs, $4 Preferred Generics; $10 Generic; For the Plus (HMO) plan, the Value (HMO) plan and Select (HMO-POS… Office Visits ($0 annual preventive exam), $3,375 inpatient maximum per calendar year, Days 1-20: $0 copay per day of the price or the Health New England negotiated price, Call (413) 787-0010 or TTY 711 for more information. Notice of Privacy Practices ... • HMO Blue New England $1,000 Deductible • HMO Blue New England $1,000 Deductible with Copayment ... changes, please refer to the Summary of Benefits or Plan Changes fact … %PDF-1.6 %���� 1807 0 obj <> endobj Over $5,100 in Out-of-Pocket Costs, $3.40 for Generics and $8.50 for all other drugs; or 5% coinsurance, $8 Preferred Generics; $20 Generic; h�bbd```b``�"�H�3 ���~��)�����@$k?�d��'�I��N0[Ln ��"��AdH=cP�V� DJ�U� ��U����D�bT&�3�f�` Z n 1832 0 obj <>/Filter/FlateDecode/ID[<2FE56E1E42F1AB48BE7954EA17A400F3>]/Index[1807 42]/Info 1806 0 R/Length 118/Prev 676668/Root 1808 0 R/Size 1849/Type/XRef/W[1 3 1]>>stream Walk-Ins: Due to COVID-19, we are not accepting walk-ins at this time. whichever is lower, Catastrophic Coverage:  28% Specialty Tier, Coverage Gap: endstream endobj 1808 0 obj <. †You must use an EyeMed® provider. Refer to the Summary of Benefits or call Member Services if you have questions about what items and services are covered. %PDF-1.6 %���� This information is not a complete description of benefits. Up to $5,100 in Out-of-Pocket Costs, 37% of the costs for generic. 1252 0 obj <>/Filter/FlateDecode/ID[<3251FF21DB51FD42AD3924706C749926><5AAB855FB3586C4F9CEF4B6DABB3ADBB>]/Index[1226 55]/Info 1225 0 R/Length 122/Prev 615060/Root 1227 0 R/Size 1281/Type/XRef/W[1 3 1]>>stream 0 )Jfh�`y�G�9��*��!��V�Ъ�AoYw�9�ٽ�}���~FC֘�\Ur�X|�Up� �e �hq�w�ĢpTh2�1 $�9�I�+�����d�۴;���oQ�, ��H��U�]ꓢ��8::*@$cGG��)&�2��P:�j��� B7�����:8�iq �{�� �f{�/�������X�����`�`9�"ü�A�3��%�"H��D���4�5ӧ�Il�ܖ���y�U�Vk�`��t�����@40��B��L �9�O��4?CT \fWD�)@� pJq� Outpatient Rehabilitation (PA after visit 25), 37% of the costs for generic.