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Advantage Blue: Summary of Benefits
Advantage Blue: Summary of Benefits
This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents effective January 1, 2011, as part of the Massachusetts Health Care Reform Law.
Your Care
Advantage Blue is an exclusive provider health care plan, commonly referred to as an EPO. You receive benefits only when you use preferred providers, except for covered emergency care. After a $500 per admission copayment, you have full coverage for covered inpatient hospital, physician, and other provider covered services. There is a $250 copayment for outpatient surgery at an ambulatory surgical facility, preferred hospital outpatient department, or surgical day care unit. And for certain other outpatient services, you pay a $25 copayment for each visit. Please 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. If the provider you use is not a preferred provider, you pay all costs even if you are referred by a preferred provider.
Dependent Benefits
This plan covers dependents up to age 26, regardless of the dependents financial dependency, student status, or employment status, unless they are eligible for coverage under a non-parent employer-sponsored plan. Please see your benefit description (and riders, if any) for exact coverage details
$25 per visit (no cost for immunizations and routine tests) $25 per visit (no cost for routine tests) $25 per visit $25 per visit (no cost for routine tests) $25 per visit $25 per visit and all charges beyond the lifetime maximum $25 per visit $25 per visit $25 per visit Nothing Nothing Nothing Nothing All charges beyond the calendar-year maximum All charges beyond the benefit maximum
Nothing $250 per admission*** $500 per admission*** $500 per admission*** $500 per admission*** $500 per admission***
******* No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care. *** No dollar limit applies when durable medical equipment is furnished as part of covered home dialysis, home health care, or hospice services. *** Copayments for consecutive inpatient admissions (or day surgery followed by inpatient care) within 30 days for the same or related illness will not exceed $500.
At Blue Cross Blue Shield of Massachusetts we offer you a group of programs, discounts and savings, resources, and tools to help you get the most you can from your health care plan. Call us at 1-800-225-2019 to receive information that outlines these special programs.
No additional charge $150 per year, per individual/family $150 per year, per individual/family Discount varies Discount varies No additional charge Up to a 30% discount No additional charge A Fitness Benefit toward membership at a health club (see your benefit description for details) Reimbursement for a Blue Cross Blue Shield of Massachusetts designated weight loss program Living Healthy Vision discounts on eyewear (frames, lenses, supplies, and laser vision correction surgery)
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Safe Beginningsdiscounts on home safety items Blue Care LineSM to answer your health care questions 24 hours a daycall 1-888-247-BLUE (2583) Living Healthy Naturally discounts on different types of complementary and alternative medicine services such as acupuncture, massage therapy, nutritional counseling, personal training, Pilates, tai chi, and yoga
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Visit www.AHealthyMe.com for an around-the-clock healthy approach to fitness, family, and fun
Limitations and Exclusions. These pages summarize the benefits of your health care plan. The benefit description and riders define the full terms and conditions
in greater detail. Should any questions arise concerning benefits, the benefit descriptions and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Please note: Blue Cross and Blue Shield of Massachusetts, Inc. administers claims payment only and does not assume financial risk for claims.
Registered Marks of the Blue Cross and Blue Shield Association. SM Service Marks of the Blue Cross and Blue Shield Association. SM Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield HMO Blue, Inc. 2010 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc.