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Plans and benefits

Our plans - Direct Care and Select Care - have different networks and levels of benefits to best fit your health care needs. To determine which plans works best for you, compare the two differences: network and benefits.

Network

Direct Care Select Care
  • More than 37,000 providers across Massachusetts
  • Tiered limited network plan with coverage in Central and Eastern Massachusetts
  • Saves you money on your health insurance premium
  • A larger, tiered network with more than 59,000 providers throughout Massachusetts, Southern New Hampshire and Southwestern Vermont

    Learn more about tiering »

List of network providers and hospitals »

 

Benefits and copayments

The chart below shows your copayments for some of the most commonly used benefits.

Direct Care Select Care

Medical deductible

$400 Individual
$800 Family

$500 Individual
$1,000 Family

Rx deductible
Administered through
Express Scripts
855-283-7679
express-scripts.com

$100 Individual
$200 Family

$100 Individual
$200 Family

Learn more about deductibles (pdf)

Out-of-pocket maximum

$5,000/$10,000

$5,000/$10,000

PCP wellness exams

$0 per visit

$0 per visit

Other PCP office visits

$15 per visit

$20 per visit

Teladoc®
Telehealth medical consultations

$15 per consult

$15 per consult

Urgent care center/Retail clinic ("Minute Clinic")

Find an in-network clinic

$15 per visit

$20 per visit

Ob/Gyn visits
Prenatal and postnatal care

Tier 1:
$10 per visit

Tier 2:
$15 per visit

 

Tier 1:
$15 per visit

Tier 2:
$20 per visit

Tier 3:
$30 per visit

Specialist visits

Tier 1:
$30 per visit

Tier 2:
$60 per visit

 

Tier 1:
$30 per visit

Tier 2:
$60 per visit

Tier 3:
$75 per visit

Prescriptions

Drug coverage provided by Express Scripts
Contact: 855-283-7679 or express-scripts.com

There is a separate $100/$200 pharmacy deductible, then the following copayments apply:

$10/30/65 Retail
$25/75/165 Mail-order

$10/30/65 Retail
$25/75/165 Mail-order

Routine eye exams

$15 per visit

$20 per visit

Outpatient mental health and substance abuse

$15 per visit

$20 per visit

Preventive services**

Covered in full

Covered in full

Diagnostic services***

Subject to deductible then covered in full

Subject to deductible then covered in full

Imaging (CAT, PET, MRI scans) (max. of one copayment per day)

$100 copayment (then subject to deductible)

$100 copayment (then subject to deductible)

Chiropractic care
(12 visits per benefit year)

$15 per visit

$20 per visit

Emergency services
(Copayments for ER services are waived if you are admitted to the hospital)

$100 copayment (then subject to deductible)

$100 copayment (then subject to deductible)

Inpatient hospital

$275 copayment per admission
(then subject to deductible)

Tier 1:
$275

Tier 2:
$500

Tier 3:
$1,500

Copayment, then subject to deductible

Outpatient surgery
Eye and GI procedures
List of free-standing ambulatory surgical centers

 

 

Non-hospital setting

$150 copayment then subject to deductible

$150 copayment then subject to deductible

Hospital setting

$250 copayment then subject to deductible

$250 copayment then subject to deductible

Outpatient surgery
All procedures except eye and gastrointestinal procedures

$250 copayment then subject to deductible

$250 copayment then subject to deductible

 

Healthy extras

With either Direct Care or Select Care, you'll get:

  • One of the most flexible fitness reimbursements in the state
    - Direct Care members - $400/family, $200/individual
    - Select Care members - $100/family, $100/individual
  • A 20% discount on CVS/pharmacy-brand health-related products
  • Eyewear discounts – save up to 35% on frames and get additional discounts on contact lenses, laser vision correction and nonprescription sunglasses
  • Quit to Win – smokers have access to this free counseling program with tobacco cessation experts who will work with you by telephone
  • And other healthy extras that you won't find with any other plan

Learn more about healthy extras

 

Additional information about our health plan benefits and policies

Find out about our Case Management, Disease Management, Behavioral Health, and more. 
Download information about your benefits and policies (pdf)

 

** Preventive services are tests, immunizations and services geared to help screen for diseases and improve early detection when symptoms or diagnosis are not present.

*** Diagnostic services are tests, immunizations and services that are intended to diagnose, check the status of, or treat a disease or condition.