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All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure. Blue Care Elect MIT Student Extended Insurance Plan PPO MIT Student Health Plan. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. The formulary and/or pharmacy network may change at any time. Enrollment in MPDP depends on contract renewal. The FEP Medicare Prescription Drug Program is a prescription drug plan with a Medicare contract. 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 2 If you have Medicare Part B primary, your costs for prescription drugs may be lower. Participating Urgent Care Centers in Massachusetts Hospital/Facility Name Address Ambulatory Employee Industrial Occupational and Urgent Care 170 University Dr., Ste.1 Under Basic Option you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care.^ What you’ll pay for a 30-day supply of covered drugs.Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.Ĭost sharing may not apply or may be different if Medicare is your primary coverage (it pays first). Tier 4 (Preferred specialty): $85 copay 2 Visit the Medicare page for more information.

Tier 5 (Non-preferred specialty): $110 copay 2Īvailable to members with Medicare Part B primary only. : Updated Individual PPO section to reflect worldwide emergency and urgently needed services and emergency transportation are subject to a combined 250 annual deductible, 20 coinsurance and a combined 50,000 lifetime maximum benefit. Tier 4 (Preferred specialty): $85 copay 2 Tier 3 (Non-preferred brand): 60% of our allowance ( $90 minimum) 2 $0 for first 2 visits and all nutrition visits Nothing for covered preventive screenings, immunizations and services