Medical Benefits

PPO $1,700

PPO plan with lower deductibles and higher premiums.

Medical Benefits

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Plan Details

NetworkBCBSTN

CarrierBCBSTN

Plan TypePPO

HSA EligibleNo

FSA EligibleYes

Out-of-Network CoverageYes

Payroll Contributions

Coverage Tier	Weekly Rate
Employee	$52.58
Employee + spouse	$165.40
Employee + child(ren)	$100.64
Employee + family	$171.67

*Medical rates shown are discounted non-tobacco rates.

Deductible, Out of Pocket & Coinsurance

Deductible and Out-of-Pocket Type

In-Network: Embedded
Out-of-Network: Embedded

Deductible (Individual)

In-Network: $1,700
Out-of-Network: $3,400

Deductible (Family)

In-Network: $3,400
Out-of-Network: $6,800

Coinsurance

In-Network: 90%
Out-of-Network: 60%

Out-of-Pocket Max (Individual)

In-Network: $2,750
Out-of-Network: $5,250

Out-of-Pocket Max (Family)

In-Network: $5,500
Out-of-Network: $10,500

Lifetime Maximum

In-Network: Unlimited
Out-of-Network: Unlimited

Feature	In-Network	Out-of-Network
Deductible and Out-of-Pocket Type	Embedded	Embedded
Deductible (Individual)	$1,700	$3,400
Deductible (Family)	$3,400	$6,800
Coinsurance	90%	60%
Out-of-Pocket Max (Individual)	$2,750	$5,250
Out-of-Pocket Max (Family)	$5,500	$10,500
Lifetime Maximum	Unlimited	Unlimited

Covered Services

Preventive Care

In-Network: $0
Out-of-Network: Not Covered

Primary Care Physician

In-Network: $20
Out-of-Network: 40%*

Specialist

In-Network: $50
Out-of-Network: 40%*

Urgent Care

In-Network: $50
Out-of-Network: 40%*

Teladoc Health

In-Network: $20
Out-of-Network: Not Covered

Emergency Room

In-Network: $200
Out-of-Network: $200

Service	In-Network	Out-of-Network
Preventive Care	$0	Not Covered
Primary Care Physician	$20	40%*
Specialist	$50	40%*
Urgent Care	$50	40%*
Teladoc Health	$20	Not Covered
Emergency Room	$200	$200

*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

Tier 4

Retail (up to 30-day supply): 30% coinsurance **
Mail Order (up to 90-day supply): —

Tier	Retail (up to 30-day supply)	Mail Order (up to 90-day supply)
Tier 1	$10	$25
Tier 2	30%; $25 min/$75 max	30%; $62.50 min/$187.50 max
Tier 3	40%; $50 min/$100 max	40%; $125 min/$250 max
Tier 4	30% coinsurance **	—

*After deductible
**If you participate in the PPO plan, you may be eligible for a copay assistance program for specialty medications. Please see your plan document for additional details at https://compass.empyreanbenefits.com/playcore

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