Deductible and Out-of-Pocket Type
- In-Network
- Embedded
- Out-of-Network
- Embedded
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Medical Benefits
HDHP $3,500
High deductible health plan with HSA eligibility.
Medical Benefits
Plan Details
NetworkBCBSTN
CarrierBCBSTN
Plan TypeHDHP
HSA EligibleYes
FSA EligibleNo
Out-of-Network CoverageYes
Payroll Contributions
| Coverage Tier | Weekly Rate |
|---|---|
| Employee | $19.47 |
| Employee + spouse | $99.48 |
| Employee + child(ren) | $36.99 |
| Employee + family | $70.92 |
- *Medical rates shown are discounted non-tobacco rates.
Deductible, Out of Pocket & Coinsurance
Deductible (Individual)
- In-Network
- $3,500
- Out-of-Network
- $7,000
Deductible (Family)
- In-Network
- $7,000
- Out-of-Network
- $14,000
Coinsurance
- In-Network
- 70%
- Out-of-Network
- 50%
Out-of-Pocket Max (Individual)
- In-Network
- $6,000
- Out-of-Network
- $12,000
Out-of-Pocket Max (Family)
- In-Network
- $12,000
- Out-of-Network
- $24,000
Lifetime Maximum
- In-Network
- Unlimited
- Out-of-Network
- Unlimited
Covered Services
Preventive Care
- In-Network
- $0
- Out-of-Network
- Not Covered
Primary Care Physician
- In-Network
- 30%*
- Out-of-Network
- 50%*
Specialist
- In-Network
- 30%*
- Out-of-Network
- 50%*
Urgent Care
- In-Network
- 30%*
- Out-of-Network
- 50%*
Teladoc Health
- In-Network
- 30%*
- Out-of-Network
- Not Covered
Emergency Room
- In-Network
- 30%*
- Out-of-Network
- 30%*
- *After deductible
Pharmacy Benefits
Tier 1
- Retail (up to 30-day supply)
- $10
- Mail Order (up to 90-day supply)
- $25
Tier 2
- Retail (up to 30-day supply)
- 30%; $25 min/$75 max
- Mail Order (up to 90-day supply)
- 30%; $62.50 min/$187.50 max
Tier 3
- Retail (up to 30-day supply)
- 40%; $50 min/$100 max
- Mail Order (up to 90-day supply)
- 40%; $125 min/$250 max
- *After deductible
Plan Notes
- Administered through CVS Caremark
- Home delivery pharmacy: CVS Caremark Mail Order Pharmacy
- Pharmacy can contact your doctor for a 90-day prescription
- Mail order shipping to your door