Health Plan Comparison

Blue Cross Blue Shield PPO*

Blue Cross Blue Shield Network Blue New England

BU Health Savings Plan with Health Savings Account*

In-Network

Out-of-Network

BMC PCP and Referrals

Non-BMC PCP and Referrals

In-Network

Out-of-Network

Applied Behavior Analysis

Applied Behavior Analysis

Applied Behavior Analysis

Covered for children between their third and seventh birthdays if they have been diagnosed with an Autism Spectrum Disorder. $20 copayment per visit; up to 20 visits per calendar year Covered for children between their third and seventh birthdays if they have been diagnosed with an Autism Spectrum Disorder. 20% coinsurance after deductible; up to 20 visits per calendar year Not covered Not covered Not covered Not covered

Chiropractic Care

Chiropractic Care

Chiropractic Care

$20 copayment per visit; up to 20 visits per calendar year 20% coinsurance after deductible; up to 20 visits per calendar year $15 copayment per visit; up to 20 visits per calendar year $40 copayment per visit; up to 20 visits per calendar year 10% coinsurance after deductible; up to 20 visits per calendar year 30% coinsurance after deductible; up to 20 visits per calendar year

Drug and Alcohol Treatment

Drug and Alcohol Treatment

Drug and Alcohol Treatment

Inpatient: You pay nothingOutpatient Calendar year benefit: Individual or group therapy: $20 copayment per visit Inpatient: 20% coinsurance after deductibleOutpatient Calendar year benefit: 20% coinsurance after deductible Inpatient: You pay nothingOutpatient Calendar year benefit: $15 copayment per visit Inpatient: You pay nothingOutpatient Calendar year benefit: $40 copayment per visit Inpatient: 30% coinsurance after deductibleOutpatient Calendar year benefit: 10% coinsurance after deductible Inpatient: 30% coinsurance after deductibleOutpatient Calendar year benefit: 10% coinsurance after deductible

Durable Medical Equipment

Durable Medical Equipment

Durable Medical Equipment

You pay nothing 20% coinsurance after deductible 20% coinsurance 20% coinsurance 10% coinsurance after deductible 30% coinsurance after deductible

Emergency Room Visit

Emergency Room Visit

Emergency Room Visit

$100 copayment per visit; waived if admitted $100 copayment per visit; waived if admitted $100 copayment per visit; waived if admitted $100 copayment per visit; waived if admitted 10% coinsurance after deductible 30% coinsurance after deductible

Family Planning

Family Planning

Family Planning

Family Planning: $20 copayment per visitInfertility Services: $20 copayment per visit in physician’s office Family Planning: 20% insurance after deductibleInfertility Services: 20% insurance after deductible $15 copayment per visit Non-BMC PCP: $30 copayment per visitNon-BMC PCP referral: $40 copayment per visit 10% coinsurance after deductible 30% coinsurance after deductible

Hospital Benefits

Hospital Benefits

Hospital Benefits

General Hospital including maternity & gender reassignment surgery: You pay nothingSkilled Nursing Facility Up to 100 days per calendar year: You pay nothing General Hospital including maternity & gender reassignment surgery: 20% coinsurance after deductibleSkilled Nursing Facility Up to 100 days per calendar year: 20% coinsurance after deductible General Hospital including maternity & gender reassignment surgery: You pay nothingSkilled Nursing Facility Up to 100 days per calendar year: You pay nothing General Hospital including maternity & gender reassignment surgery: $200 copayment per admissionSkilled Nursing Facility Up to 100 days per calendar year: You pay nothing General Hospital including maternity & gender reassignment surgery: 10% coinsurance after deductibleSkilled Nursing Facility Up to 100 days per calendar year: 10% coinsurance after deductible General Hospital including maternity & gender reassignment surgery: 0% coinsurance after deductibleSkilled Nursing Facility Up to 100 days per calendar year: 30% coinsurance after deductible

Mental Health Benefits

Mental Health Benefits

Mental Health Benefits

Inpatient: You pay nothingOutpatient Calendar year benefit: You pay nothingIndividual or group therapy: $20 copayment per visit Inpatient: 20% coinsurance after deductibleOutpatient Calendar year benefit: 20% coinsurance after deductible Inpatient: You pay nothingOutpatient Calendar year benefit: $15 copayment per visit Inpatient: You pay nothingOutpatient Calendar year benefit: $40 copayment per visit Inpatient: 10% coinsurance after deductibleOutpatient Calendar year benefit: 10% coinsurance after deductible Inpatient: 30% coinsurance after deductibleOutpatient Calendar year benefit:30% coinsurance after deductible

MRIs, CT scans, PET scans & Nuclear Cardiac Imaging

MRIs, CT scans, PET scans & Nuclear Cardiac Imaging

MRIs, CT scans, PET scans & Nuclear Cardiac Imaging

$20 copayment per visit per category per date of service 20% coinsurance after deductible $25 copayment per visit per category per date of service $50 copayment per visit per category per date of service 10% coinsurance after deductible 30% coinsurance after deductible

Physical Therapy

Physical Therapy

Physical Therapy

$20 copayment per visit; up to 60 visits per calendar year 20% coinsurance after deductible; up to 60 visits per calendar year $15 copayment per visit, up to 60 visits per calendar year Non-BMC referrals: $40 copayment per visit, up to 60 visits per calendar year 10% coinsurance after deductible; up to 60 visits per calendar year 30% coinsurance after deductible; up to 60 visits per calendar year

Physicians’ Services

Physicians’ Services

Physicians’ Services

Office Visits: $20 copayment per visitSurgical: You pay nothing Office Visits & Surgical: 20% coinsurance after deductible Office Visits & Surgical: $15 copayment per visit Office Visits & Surgical:Non-BMC PCP: $30 copayment per visitNon-BMC PCP referral to specialist: $40 copayment per visit Office Visits & Surgical: 10% coinsurance after deductible Office Visits & Surgical: 30% coinsurance after deductible

Preventive Care

Preventive Care

Preventive Care

You pay nothing 20% coinsurance after deductible You pay nothing You pay nothing You pay nothing 30% coinsurance after deductible

Eye Exams

Eye Exams

Eye Exams

You pay nothing 20% coinsurance after deductible You pay nothing You pay nothing You pay nothing 30% coinsurance after deductible

Deductible

Deductible

Deductible**

None $500 per person; $1,000 per family None None $1,500 employee only; $3,000 any family plan $3,000 employee only; $6,000 any family plan

Out-of-Pocket Maximum

Out-of-Pocket Maximum

Out-of-Pocket Maximum**

$2,500 per person; $5,000 per family (includes deductible) $2,500 per person; $5,000 per family (includes deductible) $2,500 per person; $5,000 per family $2,500 per person; $5,000 per family $3,000 employee only;
$6,000 any family plan (including deductible)
$6,000 employee only;
$12,000 any family plan (including deductible)

Lifetime Maximum Benefit

Lifetime Maximum Benefit

Lifetime Maximum Benefit

No limit No limit No limit No limit No limit No limit

Provider Choice

Provider Choice

Provider Choice

You must use a network participating provider. You may use the provider of your choice. Your care must be coordinated in advance by your primary care physician (PCP). Your care must be coordinated in advance by your primary care physician (PCP). You must use a network participating provider. You may use the provider of your choice.

Copayment per visits

Copayment per visits

Copayment per visits

$20 per visit for most covered services Depending on the service, generally 20% coinsurance after deductible $15 per visit for most covered services Non-BMC PCP: $30 copayment per visitNon-BMC PCP referral to specialist: $40 copayment per visit per visit Depending on the service, generally 10% coinsurance after deductible Depending on the service, generally 30% coinsurance after deductible

Benefit Level

Benefit Level

Benefit Level

You pay nothing for most inpatient and outpatient services; $20 copayment per visit for some services 20% coinsurance for most covered inpatient and outpatient services after deductible is met You pay nothing for most inpatient and outpatient services; $15 copayment per visit for some services Non-BMC PCP: You pay nothing for most inpatient and outpatient services; $30 copayment per visit for some servicesNon-BMC PCP referrals: You pay nothing for most inpatient and outpatient services; $40 copayment per visit for some services 10% coinsurance after high deductible is met for inpatient and outpatient services 30% coinsurance after high deductible is met for inpatient and outpatient services

Claim Forms

Claim Forms

Claim Forms

Not required Required Not required Not required Required Required

Prescription Drugs

Prescription Drugs

Prescription Drugs

Retail Pharmacy for up to a 30-day supply Home Delivery for up to a 90-day supply Retail Pharmacy for up to a 30-day supply Home Delivery for up to a 90-day supply Retail Pharmacy for up to a 30-day supply Home Delivery for up to a 90-day supply
Generic medication:$8 copayment Preferred brand-name medication: 20% coinsurance (minimum cost $30; maximum cost $50/prescription)Non-preferred brand-name medication: 30% coinsurance (minimum cost $50; maximum cost $70/prescription) Generic medication:$16 copaymentPreferred brand-name medication: 20% coinsurance (minimum cost $60; maximum cost $100/prescription)Non-preferred brand-name medication: 30% coinsurance (minimum cost $100; maximum cost $140/prescription) Generic medication:$8 copaymentPreferred brand-name medication: 20% coinsurance (minimum cost $30; maximum cost $50/prescription)Non-preferred brand-name medication: 30% coinsurance (minimum cost $50; maximum cost $70/prescription) Generic medication: $16 copayment Preferred brand-name medication: 20% coinsurance (minimum cost $60; maximum cost $100/prescription)Non-preferred brand-name medication: 30% coinsurance (minimum cost $100; maximum cost $140/prescription) 10% coinsurance after deductible 10% coinsurance after deductible


*Annual maximums are combined in-network and out-of-network.

**The family deductible and out-of-pocket maximum can be met by amounts paid by one family member or any combination of family members enrolled under the same family plan. The entire amount of the family deductible must be met before benefits will be provided for any other member.