HMO Blue New England Plan

• $20 office visit co-pay.
• $20 chiropractic visit co-pay.
• $150 high cost diagnostics (MRI, MRA, CT, CAT, PET & SPECT) co-pay.
• $250 outpatient surgery co-pay.
• $250 inpatient co-pay.
• $100 emergency room co-pay.
• Outpatient Lab, X-ray and Ultrasound services covered in full.
• Skilled Nursing Facility Care covered in full.
• Rehabilitation Facility Care covered in full.
• Preventative Care Immunizations, lead screening, PSA (prostate screening), mammograms and PAP smears covered in full.
• Chiropractic X-rays covered in full.
• Ambulance services (medically necessary emergency transport only) covered in full.
• Durable Medical Equipment (DME) covered in full.

Mental Health and Substance Abuse services must be authorized by Behavioral Health Network at (888) 364-8665:

• Outpatient mental health and substance abuse services $20 co-pay.
• Inpatient mental health and substance abuse services $250 co-pay.

Prescription Drug Benefits

$150 deductible per family, then:  (Does Not Apply to Generic Drugs)

• Retail 30-day supply co-payments - $10 generic drugs,$25 preferred brand name,$40 non-preferred brand name.
• Mail order 90-day supply for certain maintenance rugs - co-payments - $20 generic drugs,$50 preferred brand name,$80 non-preferred brand name.

Please note: this is only a brief summary of coverage. Benefits apply when care is medically necessary. Services are covered up to the Maximum Allowable Benefit (MAB). Network providers agree to accept the MAB as payment in full. However, if you receive services from an out-of-network provider, it is your responsibility to pay the difference between the MAB and the provider's charge.