Page 4 - 2018 Adult & Pediatric Dermatology Guide
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2018–19 BENEFITS ENROLLMENT
MEDICAL AND PRESCRIPTION DRUG
AP Derm offers a robust medical insurance program to our employees. We partner with Blue Cross Blue Shield of
Massachusetts to offer this coverage.
Medical Benefit Summary
(1)
Access BLUE NE Saver Preferred Blue PPO Saver 2000 Plan (PPO Plan)
2000 Plan (HMO Plan)
In-Network In-Network Out-of-Network
Plan Year Deductible
Individual $2,000 $2,000 $2,000
Family $4,000 $4,000 $4,000
Plan Year Out
Individual $6,450 $6,450 $6,450
Family $12,900 $12,900 $12,900
Physician Office Visits
Preventive Care Covered at 100% Covered at 100% 80% after deductible
Primary Care Visit $15 copay after deductible 100% after deductible 80% after deductible
Specialist Visit $25 copay after deductible 100% after deductible 80% after deductible
Chiropractic Care $25 copay after deductible 100% after deductible 80% after deductible
Urgent Care $25 copay after deductible 100% after deductible 80% after deductible
Hospital Services
Inpatient 100% after deductible 100% after deductible 80% after deductible
Outpatient 100% after deductible 100% after deductible 80% after deductible
Emergency Room $150 copay after deductible $150 copay after deductible
Prescription Drugs
Retail—Supply Limit 30-Day Supply
Tier 1 $10 copay after deductible $10 copay after deductible $20 copay after deductible
Tier 2 $25 copay after deductible $25 copay after deductible $50 copay after deductible
Tier 3 $45 copay after deductible $45 copay after deductible $90 copay after deductible
Mail Order—Supply Limit 90-Day Supply
Tier 1 $20 copay after deductible $20 copay after deductible Not covered
Tier 2 $50 copay after deductible $50 copay after deductible Not covered
Tier 3 $135 copay after deductible $135 copay after deductible Not covered
Value Drugs for Asthma, Diabetes, and Coronary Artery Disease—Deductible Does Not Apply
Tier 1 $10 copay $10 copay Not covered
Tier 2 $25 copay $25 copay Not covered
Tier 3 $135 copay $135 copay Not covered
(1) This is a high-level summary of your benefit coverage. Full coverage details are available in your summary plan description (SPD).
In the event there is a discrepancy between what is reflected in this guide and what is communicated in your SPD, the terms of
your SPD will prevail.
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MEDICAL AND PRESCRIPTION DRUG
AP Derm offers a robust medical insurance program to our employees. We partner with Blue Cross Blue Shield of
Massachusetts to offer this coverage.
Medical Benefit Summary
(1)
Access BLUE NE Saver Preferred Blue PPO Saver 2000 Plan (PPO Plan)
2000 Plan (HMO Plan)
In-Network In-Network Out-of-Network
Plan Year Deductible
Individual $2,000 $2,000 $2,000
Family $4,000 $4,000 $4,000
Plan Year Out
Individual $6,450 $6,450 $6,450
Family $12,900 $12,900 $12,900
Physician Office Visits
Preventive Care Covered at 100% Covered at 100% 80% after deductible
Primary Care Visit $15 copay after deductible 100% after deductible 80% after deductible
Specialist Visit $25 copay after deductible 100% after deductible 80% after deductible
Chiropractic Care $25 copay after deductible 100% after deductible 80% after deductible
Urgent Care $25 copay after deductible 100% after deductible 80% after deductible
Hospital Services
Inpatient 100% after deductible 100% after deductible 80% after deductible
Outpatient 100% after deductible 100% after deductible 80% after deductible
Emergency Room $150 copay after deductible $150 copay after deductible
Prescription Drugs
Retail—Supply Limit 30-Day Supply
Tier 1 $10 copay after deductible $10 copay after deductible $20 copay after deductible
Tier 2 $25 copay after deductible $25 copay after deductible $50 copay after deductible
Tier 3 $45 copay after deductible $45 copay after deductible $90 copay after deductible
Mail Order—Supply Limit 90-Day Supply
Tier 1 $20 copay after deductible $20 copay after deductible Not covered
Tier 2 $50 copay after deductible $50 copay after deductible Not covered
Tier 3 $135 copay after deductible $135 copay after deductible Not covered
Value Drugs for Asthma, Diabetes, and Coronary Artery Disease—Deductible Does Not Apply
Tier 1 $10 copay $10 copay Not covered
Tier 2 $25 copay $25 copay Not covered
Tier 3 $135 copay $135 copay Not covered
(1) This is a high-level summary of your benefit coverage. Full coverage details are available in your summary plan description (SPD).
In the event there is a discrepancy between what is reflected in this guide and what is communicated in your SPD, the terms of
your SPD will prevail.
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