Medical Plan Comparison

	HMO Blue New England	HMO Blue New England $500 Deductible	Blue Care Elect $500 Deductible PPO	Blue Care Elect Saver PPO with HSA
Annual Plan Year Deductible (In-Network)
Employee	$0	$500	$500	$1,600
Employee +1 / Family	$0	$1,000 ^{($500 per member)}	$1,000 ^{($500 per member)}	$3,200
HSA eligible?	No	No	No	Yes
College Contribution	Not Applicable	Not Applicable	Not Applicable	HSA (regardless of your contribution)
Employee	$0	$0	$0	$500
Employee +1 / Family	$0	$0	$0	$1,000

	HMO Blue New England	HMO Blue New England $500 Deductible	Blue Care Elect $500 Deductible PPO	Blue Care Elect Saver PPO with HSA
Medical Annual Out-of-Pocket Maximum (In-Network)
Employee	$2,000	$1,500	$1,500	$3,200
Employee +1 / Family	$4,000	$3,000	$3,000	$6,400
Prescription Annual Out-of-Pocket Maximum (In-Network)
Employee	$1,000	$1,000	$1,000	Combined with medical out-of-pocket maximum
Employee +1 / Family	$2,000	$2,000	$2,000	Combined with medical out-of-pocket maximum

	HMO Blue New England	HMO Blue New England $500 Deductible	Blue Care Elect $500 Deductible PPO	Blue Care Elect Saver PPO with HSA
Co-Pays (In-Network)
Primary Care Visit	$20	$20	$30	Deductible First
Preventive Care / Prenatal	No Charge	No Charge	No Charge	No Charge
Specialist Visit / Chiropractor	$30	$30	$30	Deductible First
Outpatient Mental Health / Substance Use	$20	$20	$30	Deductible First
Diagnostic Tests / Imaging	No Charge	Deductible First	Deductible First	Deductible First
Rehabilitation Services	$30	$30	$30	Deductible First
Durable Medical Equipment	20% Co-Insurance	Deductible First 20% Co-Insurance	Deductible First 20% Co-Insurance	Deductible First 20% Co-Insurance
Outpatient Surgery	$250	Deductible First	Deductible First	Deductible First
Urgent Care	$30	$30	$30	Deductible First
Emergency Room (waived if admitted)	$100	$100	$100	$100 after Deductible
Inpatient Hospitalization / Mental Health / Substance Use	$500	Deductible First (No Charge Mental Health/Substance Use)	Deductible First	Deductible First
Annual Eye Exam	No Charge	No Charge	No Charge	No Charge
Prescription Co-Pays (In-Network)
Generic Drug (Retail/Mail Order 90 days)	$10/$20	$10/$20	$10/$20	$10/$20 after Deductible
Preferred Brand Name / Formulary (Retail/Mail Order 90 days)	$25/$50	$25/$50	$25/$50	$25/$50 after Deductible
Non-Preferred Brand Name / Non-Formulary (Retail/Mail Order 90 days)	$45/$90	$45/$90	$45/$90	$45/$90 after Deductible