Non- ER Medical Individual/ Family HMO Value 250 $15 $100 $250 $100 No 26% Basic 25 $25 $125 $500 $100 No $2,500/$5,000 17% 500 after after after $500/$1,000 8% 1000 after after after 1 (baseline) * after after after $1,500/$3,000-8% after after after -10% HMO (80%) $30 $20/$75/$100 Mail: $40/$150/$300-19% * Plan is also available with a prescription deductible of $250 individual/$500 family and $20/$75/$100 copayments. HMO products offered by Tufts Associated Health Maintenance Organization, Inc. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Non- Office Visit ER Surgical Day Care Inpatient Medical PPO In-network Out-of-network Value $15 $100 $250 $250 $100 $500/$1,000 Out-of-network 59% Basic 25 $25 $125 $500 $500 $100 $750/$1,500 Out-of-network $2,500/$5,000 $3,500/$7,000 46% 500 after $500/$1,000 38% 1000 after 27% after $1,500/$3,000 12% after 8% PPO (80/60) $30 40% $20/$75/$100 Mail: $40/$150/$300-6% PPO deductibles and out-of-pocket maximums track separately for and services. PPO products offered by Tufts Associated Health Maintenance Organization, Inc., Tufts Insurance Company, or Tufts Benefit Administrators, Inc., all Tufts Health Plan companies. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice. This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a of Benefits formore information or refer to your Evidence of Coverage for complete information.
Day Surgery Center Diagnostic Tests Annual Out-of- Pocket Maximum PCP Specialist ER Inpatient Surgery Center Center or Other Any Non Medical Individual/ Family Pediatric Dental: One child/two or more children Pharmacy Retail s YOUR CHOICE HMO A ed Network Option Your Choice HMO 3- Option 9-1 2 3 $25 $35 $200 $35 $45 $200 $45 $55 $200 $500 $750 $1,000 $500 $500 $750 $1,000 $100 $100 $350 $750 $250/$500 $20* $35 $1,400/$2,800 Pediatric Dental: $50-7% Your Choice HMO 3- Option 10-1 2 3 $25 $35 $150 $35 $50 $150 $50 $75 $150 $250 $150 $500/$1,000 $2,950/$5,900 $15* $30 $2,400/$4,800 Pediatric Dental: $50 * Mail Order 90-day supply is available at the 60-day supply copayment for 1 and 2 medications. 3 medications require the 90-day supply copayment. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Day Surgery Center Diagnostic Tests Annual Out-of- Pocket Maximum PCP Specialist ER Inpatient Surgery Center Center or Other Any Non Medical Individual/ Family Pediatric Dental: One child/two or more children Pharmacy Retail s YOUR CHOICE HMO A ed Network Option Your Choice HMO 2- Option 8-1 $25 $40 $200 2 $50 $70 $200 $500 $1,000 $250 $500 $1,000 $150 $200 $450 $750/$1,500 $2,950/$5,900 $2,400/$4,800 $15* Pediatric Dental: $35 3 $50 Your Choice HMO 2- Option 9-1 $25 $40 $150 2 $50 $70 $150 $1,000 $250 $1,000 $150 $450 $2,950/$5,900 $2,400/$4,800 $15* Pediatric Dental: $30 3 $50 * Mail Order 90-day supply is available at the 60-day supply copayment for 1 and 2 medications. 3 medications require the 90-day supply copayment. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Non- ER Medical Annual Out-of-Pocket Maximum Includes medical, pharmacy and pediatric dental services ADVANTAGE SAVER (HSA qualified plans that can be coupled with an HSA or HRA) HMO Saver after after after after $1,500/$3,000 $3,125/$6,250 Mail: $30/$60/$150-13% HMO Saver after after after after $5,350/$10,700 $20/$75/$100 Mail: $40/$150/$300-24% PPO Saver after after after after $1,500/$3,000 $3,125/$6,250 Mail: $30/$60/$150 10% PPO Saver after after after after $5,350/$10,700 $20/$75/$100 Mail: $40/$150/$300-2% PPO products offered by Tufts Associated Health Maintenance Organization, Inc., Tufts Insurance Company, or Tufts Benefit Administrators, Inc., all Tufts Health Plan companies. PPO/ products offered by Tufts Insurance Company, or Tufts Benefit Administrators, Inc., both Tufts Health Plan companies. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Non- ER Medical SELECT NETWORK Select HMO Basic 25/500 $25 $125 $500 $100 $2,500/$5,000 4% Select HMO 500 after after after $500/$1,000 Select HMO 1000 after after after -11% Select HMO after after after $1,500/$3,000-18% Select HMO after after after - STEWARD COMMUNITY CHOICE Plan $15 $150 $250 $100 No 6% 1000 after after after -16% after after after $1,500/$3,000-23% after after after -25% HMO products offered by Tufts Associated Health Maintenance Organization, Inc. Select Network plans are available to all Massachusetts employers except those located in Berkshire, Nantucket, and Dukes counties. Mandatory mail order applies for all maintenance medications on Steward Community Choice Plans. Steward Community Choice is a limited provider network product. The employer group must have a work site in the Steward Community Choice Service Area. Employees must reside or physically work in the Steward Community Choice Service Area in order to be eligible for the plan. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.
Non- ER Medical COMMONWEALTH PLANS HMO 25 Version 2 $25 PCP $40 Specialist $150 $500 $150 $1,200/$2,400 $800/$1,600 19% HMO 500 $20 PCP $35 Specialist $100 after $100 after $500/$1,000 $1,150/$2,300 $350/$700 $15/$25/$45 Mail: $30/$50/$135 7% HMO 400 with $20 PCP $35 Specialist 30% after 30% after 30% after 35% $400/$800 $100/$200 for 2 and 3 $15/50%/50% Mail: for 2 and 3 $30/50%/50% -9% HMO 1000 Version 2 $30 PCP $45 Specialist $150 after : $250 after Inpatient: $500 after $200 after $3,000/$6,000 $20/$30/$50 Mail: $40/$60/$150 HMO $25 PCP $40 Specialist $150 after $250 after $150 after $1,500/$3,000 $3,000/$6,000 $15/$25/$50 Mail: $30/$50/$150-10% HMO Version 4 $35 PCP $60 Specialist $350 after $1,000 after $400 after $1,400/$2,800 $25/$50/$75 Mail: $50/$100/$225-33% Mandatory mail order applies for all maintenance medications on plans. relativity as compared to HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice.