Medical Plan Comparison

HMO Blue New
England

HMO Blue New
England
$500 Deductible

Blue Care Elect
$500 Deductible PPO

Blue Care Elect
Saver $1500
PPO with HSA

Annual Plan Year Deductible (In-Network)

Employee

$0

$500

$500

$1,500

Employee +1 / Family

$0

$1,000
($500 per member)

$1,000
($500 per member)

$3,000

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 $1500
PPO with HSA

Medical Annual Out-of-Pocket Maximum (In-Network)

Employee

$2,000

$1,500

$1,500

$3,000

Employee +1 / Family

$4,000

$3,000

$3,000

$6,000

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 $1500
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