Below is a summary of your plan benefits. For more details view your plan Benefit Description.

On this Page:

• How the Plan Works
• Urgent and Emergency Care
• Preventive Care
• Outpatient Care
• Inpatient Care
• Prescriptions

How the Plan Works

Primary Care Provider

You must choose a primary care provider (PCP) for you and each member on the plan from the HUGHP network of participating providers. To find a HUGHP PCP visit our Find a Doctor webpage or call us at 617-495-2008.

Service Area

The plan’s service area includes all cities and towns in the Commonwealth of Massachusetts.
Note: Urgent and emergency services are covered when outside the service area.

Out-of-Pocket Maximum

This is the most that you could pay during a plan year for copayments for covered services.
$2,000 per member (or $6,000 per family) for plan-approved services.

Referrals

Services that do not require a referral:

• Behavioral Health outpatient office visits

• Chiropractor

• Emergency medical care

• Nutrition counseling

• OB/GYN

• Ophthalmologist/Optometrist for routine eye exams only (requires a referral for a diagnostic or sick visit)

Urgent and Emergency Care

Emergency Room Services

A suspected heart attack, stroke, poisoning, loss of consciousness, are examples of medical emergencies.
$100 copayment. This fee is waived if you’re admitted to the hospital or for an observation stay. Go directly to the nearest medical facility or call 911 (or the local emergency phone number).

Urgent Care

A sprained ankle, an earache, and a fever are examples of illnesses and injuries that may require urgent care.
$25 copayment. If you need urgent care, your PCP’s office will schedule an appointment if necessary, and tell you where to go to seek treatment. 

Well Connection/Telehealth Video Visits

Providers are accessible 24 hours a day, 7 days a week, 365 days a year for non-emergency care. Receive medical and behavioral health care using your smartphone, tablet, or computer.
$15 copayment.

Preventive Care

Routine Exams

For annual physicals, eye exams for eyeglasses, hearing exams, and GYN exams.
$0 copayment.

Outpatient Care

Medical and Specialty Office Visits

$25 copayment.

Mental Health or Substance Use Treatment

$25 copayment: Office visit     $15 copayment: Telemedicine

Chiropractor Office Visits

Up to 18 visits per calendar year.
$25 copayment.

Physical and Occupational

Up to 60 visits each per calendar year.
$25 copayment.

Diagnostic X-Rays and Lab Tests

$0 copayment.

CT Scans, MRIs, PET Scans, and Nuclear Cardiac Imaging Tests

$50 copayment per category and per service date.

Surgery and Related Anesthesia

• Office or health center services: $25 copayment.
• Ambulatory surgical facial facility, hospital outpatient department, or surgical day care unit: $100 per admission.

Inpatient Care

General or Chronic Disease Hospital Care

$100 per admission.

Mental Health Substance Use Facility Care

$100 per admission.

Prescriptions

You can fill most prescription drugs two ways:

1. A Participating Pharmacy

Copayment at a participating pharmacy for up to a 30-day supply:

• Tier 1: Most generic drugs - $7
• Tier 2: Preferred brand name drugs - $20
• Tier 3: Non-preferred brand name drugs - $45

2. Mail Order Through Express Scripts

Discounted copayments through Express Scripts mail order for a 90-day supply:

• Tier 1: Most generic drugs - $14
• Tier 2: Preferred brand name drugs - $50
• Tier 3: Non-preferred brand name drugs - $110

Below is a summary of your plan benefits. For more details view your plan Benefit Description.

On this Page:

• How the Plan Works
• Urgent and Emergency Care
• Preventive Care
• Outpatient Care
• Inpatient Care
• Prescriptions

How the Plan Works

To receive the highest level of coverage, you must choose a HUGHP primary care provider (PCP) and obtain your health care services and supplies from covered providers who participate in your health plan’s provider network.

Primary Care Provider 

You must choose a primary care provider (PCP) for you and each member on the plan from the HUGHP network of participating providers. To find a HUGHP PCP visit our Find a Doctor webpage or call us at 617-495-2008.

POS members can select an out-of-network primary care physician but will have higher out-of-pocket costs. Review your Benefit Description for details.

Service Area

The plan’s service area includes all cities and towns in the Commonwealth of Massachusetts. To receive the highest level of benefits, any additional follow-up care must be arranged by your PCP.
Note: Urgent and emergency services are covered at the plan benefits level when outside the service area, (see urgent and emergency care for details).

Deductible

This is the cost you pay out-of-pocket before you can receive coverage for some benefits under this plan.

• $750 per member (or $2,500 per family) for self-referred services.

Coinsurance

This is the percentage you may have to pay for a covered service after the deductible is met for self-referred care.
30% coinsurance after deductible.

Out-of-Pocket Maximum

This is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services.

• $2,000 per member (or $6,000 per family) for plan-approved services
• $2,500 per member (or $7,500 per family) for self-referred services

Referrals

Most visits with a specialist will require a referral from your primary care provider before your appointment. Otherwise, you may have to pay all costs associated with the appointment. If the specialist you were referred to wants you to see another provider, contact your primary care physician to get a referral for any other visits. 

POS members have the flexibility to seek care without a referral and to see providers not in the HUGHP network. If you use your out-of-network benefits your out-of-pocket costs will be higher.

Not all services will require a referral. See your Benefit Description for details (coming soon). 

Services that Do Not Require a Referral

• Behavioral Health outpatient office visits
• Chiropractor
• Emergency medical care
• Nutrition counseling
• OB/GYN
• Ophthalmologist/Optometrist for routine eye exams only (requires a referral for a diagnostic or sick visit)

Out-of-Network Providers or Self-Referred Care

POS  members have the option of managing their own health care and receiving care from providers who are not in the Harvard University Group Health Plan network. If you decide to use your out-of-network benefits, your out-of-pocket costs will be higher. Additionally, you may be balance billed for the difference between the actual charges and the Blue Cross Blue Shield of Massachusetts allowed amount for covered services.

Claims Process
If you elect to use your out-of-network benefits, you may have to pay for covered services rendered and file for reimbursement using this Blue Cross Blue Shield of Massachusetts claim form. Once you have met your deductible, you will be reimbursed for covered services minus your applicable coinsurance. You can view the status of your claim at Blue Cross Blue Shield MyBlue - it can take up to 60 days to process a claim. You will need to create a secured login to view the status of your claim. Learn more about the claims process.

Urgent and Emergency Care

Emergency Room Services

A suspected heart attack, stroke, poisoning, and loss of consciousness, are examples of medical emergencies. Go directly to the nearest medical facility or call 911 (or the local emergency phone number).
In-Network: $100 copayment. This fee is waived if you’re admitted to the hospital or for an observation stay.
Out-of-Network: $100 copayment. Deductible does not apply. This fee is waived if you’re admitted to the hospital or for an observation stay. 

Urgent Care 

A sprained ankle, an earache, and a fever are examples of illnesses and injuries that may require urgent care.
In-Network and out-of-network: The copayment you are charged will depend on where you are seen. Contact your primary care physician within 48 hours of receiving urgent care. 

Well Connection/Telemedicine Video Visits

Receive urgent medical and behavioral health care using your smartphone, tablet, or computer. No referral is needed. Providers are accessible 24 hours a day, 7 days a week, 365 days a year for non-emergency care.
In-Network: $25 copayment. Must use a Well Connection provider or BCBS HMO Blue provider, your appointments would be covered with applicable office visit copay. You may be asked to provide your credit card number to pay for your copay, just as you would at a doctor’s office.
Out-of-Network: 30% coinsurance.

Preventive Care

Routine Exams

For annual physicals, eye exams for eyeglasses, hearing exams, and GYN exams. One per calendar year.
In-Network: $0 copayment. 
Out-of-Network: 30% coinsurance.

Outpatient Care

Medical and Specialty Office Visits

In-Network: $25 copayment. 
Out-of-Network: 30% coinsurance.

Mental Health or Substance Use Treatment

In-Network: $25 copayment. 
Out-of-Network: 20% coinsurance.

Chiropractor Office Visits

Up to 18 visits per calendar year.
In-Network: $25 copayment. 
Out-of-Network: 30% coinsurance.

Physical and Occupational

Up to 60 visits each per calendar year.
In-Network: $25 copayment. 
Out-of-Network: 30% coinsurance.

Diagnostic X-Rays and Lab Tests

In-Network: $0 copayment. 
Out-of-Network: 30% coinsurance.

CT Scans, MRIs, PET Scans, and Nuclear Cardiac Imaging Tests

In-Network: $50 copayment per category of service. 
Out-of-Network: 30% coinsurance.

Surgery and Related Anesthesia

• Office or health center services: In-Network: $25 copayment; Out-of-Network: 30% coinsurance.
• Ambulatory surgical facial facility, hospital outpatient department, or surgical day care unit: In-Network: $100 copayment; Out-of-Network: 30% coinsurance.

Inpatient Care

General or Chronic Disease Hospital Care

In-Network: $100 copayment.
Out-of-Network: 30% coinsurance.

Mental Health Substance Use Facility Care

In-Network: $100 copayment.
Out-of-Network: 30% coinsurance.

Prescriptions

You can fill most prescription drugs two ways:

1. A Participating Pharmacy

Copayment at a participating pharmacy for up to a 30-day supply:

• Tier 1: Most generic drugs - $7
• Tier 2: Preferred brand name drugs - $20
• Tier 3: Non-preferred brand name drugs - $45

2. Mail Order Through Express Scripts

Discounted copayments through Express Scripts mail order for a 90-day supply:

• Tier 1: Most generic drugs - $14
• Tier 2: Preferred brand name drugs - $50
• Tier 3: Non-preferred brand name drugs - $110