Medical Benefits

PPO $2,700

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	$39.80
Employee + spouse	$138.67
Employee + child(ren)	$76.60
Employee + family	$132.56

*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: $2,700
Out-of-Network: $5,400

Deductible (Family)

In-Network: $5,400
Out-of-Network: $10,800

Coinsurance

In-Network: 80%
Out-of-Network: 60%

Out-of-Pocket Max (Individual)

In-Network: $4,000
Out-of-Network: $8,000

Out-of-Pocket Max (Family)

In-Network: $8,000
Out-of-Network: $16,000

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)	$2,700	$5,400
Deductible (Family)	$5,400	$10,800
Coinsurance	80%	60%
Out-of-Pocket Max (Individual)	$4,000	$8,000
Out-of-Pocket Max (Family)	$8,000	$16,000
Lifetime Maximum	Unlimited	Unlimited

Covered Services

Preventive Care

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

Primary Care Physician

In-Network: $25
Out-of-Network: 40%*

Specialist

In-Network: $60
Out-of-Network: 40%*

Urgent Care

In-Network: $60
Out-of-Network: 40%*

Teladoc Health

In-Network: $25
Out-of-Network: Not Covered

Emergency Room

In-Network: $250
Out-of-Network: $250

Service	In-Network	Out-of-Network
Preventive Care	$0	Not Covered
Primary Care Physician	$25	40%*
Specialist	$60	40%*
Urgent Care	$60	40%*
Teladoc Health	$25	Not Covered
Emergency Room	$250	$250

*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