Medical & Prescription Drug Coverage
Our Benefits4Me program offers a range of medical options, so you can choose the plan that’s best for you. All employees have access to three plans administered by Blue Cross Blue Shield of Massachusetts (BCBSMA).
If you’re in California, you also have access to a Kaiser HMO.
The Core, Buy-Up, and Consumer Choice Plans include prescription drug benefits through Express Scripts. Kaiser HMO participants receive prescription drug benefits through Kaiser.
Check out the Comparing Coverage tab to learn more about the differences among the plans.
There are some easy ways to save money on healthcare.
Use in-network providers. These providers have agreed to negotiated rates for services and supplies. And, if you live in California and enroll in the Kaiser HMO, you are required to use in-network providers for non-emergency care.
To find BCBSMA in-network providers, contact Included Health at 1-833-938-9948 or:
If you live in California and enroll in the Kaiser HMO, you are required to use in-network providers for non-emergency care.
To find Kaiser in-network providers, contact Kaiser at 1-800-464-4000 or visit kp.org.
Visit Blue Distinction Centers. These facilities offer bariatric surgery, spine surgery, and knee/hip replacements. When you visit one of these facilities, you won’t pay any coinsurance after you meet your annual deductible.
Note for Employees in Hawaii and Puerto Rico
Employees in Hawaii and Puerto Rico have different medical plans available; the descriptions in this section do not apply to you. For basic features of these plans, see the plan’s Summary of Benefits and Coverage (SBC) posted on the Additional Resources page.
Each medical plan option offers comprehensive coverage, including prescription drug coverage, preventive care at no cost to you (when you use in-network providers), and financial protection in the event of a serious illness or injury. However, the way you receive care and pay for coverage varies with each option, as does the tax-advantaged account you can use to pay for eligible expenses.
As you decide which medical option best suits your needs, consider how the options differ in their costs:
How Well Do Your Benefits Fit Today?
You can change your benefits each year (or when needed due to a Qualifying Life Event—review Making Mid-Year Changes Due to a Life Event). It’s a good idea to consider your lifestyle, your health, and your finances as you choose your coverage. The Decision Support Tool on Benefits4MeEnroll.com is an easy-to-use online tool that helps you make informed decisions about which plan best meets your needs and preferences. In the meantime, review the Coverage Chart for a summary of what’s covered under each plan and how much you may need to pay out of pocket.
When choosing your medical plan option, consider your typical medical needs and what changes, if any, you and/or your family may experience in the coming year. For example, if you plan to expand your family or know you will be having specific medical procedures, you will want to consider which coverage best suits your needs. There’s more to your medical plan options than your per paycheck cost. Depending on how you use your coverage, you may see significant tax savings in one option versus another.
Here are the key differences among the plans:
|
Core Plan |
Buy-Up Plan |
Consumer Choice Plan |
Kaiser HMO Plan |
|||||
|---|---|---|---|---|---|---|---|---|
|
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
|
|
Annual Deductible |
||||||||
|
Individual1 |
$500 |
$1,000 |
$200 |
$600 |
$1,650 |
$3,300 |
$0 |
N/A |
|
Family1 |
$1,000 |
$2,000 |
$400 |
$1,200 |
$3,300 |
$6,600 |
$0 |
N/A |
|
Coinsurance |
||||||||
|
20% |
40% |
10% |
30% |
10% |
30% |
0% |
N/A |
|
|
Annual Out-of-Pocket Maximum |
||||||||
|
Individual2 |
$3,000 |
$6,000 |
$2,000 |
$4,000 |
$3,500 |
$7,000 |
$1,500 |
|
|
Family2 |
$6,000 |
$12,000 |
$4,000 |
$8,000 |
$7,000 |
$14,000 |
$3,000 |
|
|
Covered Services |
||||||||
|
Preventive services |
Covered in full |
Deductible, then 40% |
Covered in full |
Deductible, then 30% |
Covered in full |
Deductible, then 30% |
Covered in full |
Not covered |
|
Emergency room (waived if admitted) |
$150 |
$150 |
$150 |
$150 |
Deductible, then 10% |
Deductible, then 10% |
$75 |
$75 |
|
Urgent care |
$25 |
$50 |
$20 |
$40 |
Deductible, then 10% |
Deductible, then 20% |
$20 |
Not covered |
|
Primary care physician office visit |
$25 |
Deductible, then 40% |
$20 |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Telehealth primary and mental healthcare visit through Firefly Health, Carbon Health, Well Connection |
Covered in full |
Not covered |
Covered in full |
Not covered |
Deductible, then covered in full |
Not covered |
Not applicable |
Not applicable |
|
Specialist office visit |
$35 |
Deductible, then 40% |
$35 |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Inpatient admission |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$250 |
Not covered |
|
Outpatient surgery |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Diagnostic X-rays, lab tests, and other tests at an independent lab or outpatient facility3 |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Not covered |
|
Allergy injections |
Covered in full |
Deductible, then 40% |
Covered in full |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Not covered |
|
Hearing aid (once every 3 years) |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$2,000 allowance per device |
Not covered |
|
Vision exam (one routine exam per member per calendar year) |
Covered in full |
Deductible, then 40% |
Covered in full |
Deductible, then 30% |
Covered in full |
Deductible, then 30% |
Covered in full |
Not covered |
|
Short-term, outpatient rehabilitation therapy visit |
$35 |
Deductible, then 40% |
$30 |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Chiropractic services |
$35 |
Deductible, then 40% |
$30 |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$15 |
Not covered |
|
Speech, hearing, language disorder treatment |
$35 |
Deductible, then 40% |
$30 |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Durable medical equipment |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Not covered |
|
Prosthetic devices |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Covered in full |
|
Home healthcare and hospice care |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Not covered |
|
Inpatient skilled nursing facility (100 days) |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
Covered in full |
Not covered |
|
Inpatient mental health and substance abuse |
Deductible, then 20% |
Deductible, then 40% |
Deductible, then 10% |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$250 per admission |
Not covered |
|
Outpatient mental health and substance abuse |
$25 at physician’s office; 20% for other outpatient services |
Deductible, then 40% |
$20 at physician’s office; 10% for other outpatient services |
Deductible, then 30% |
Deductible, then 10% |
Deductible, then 30% |
$20 |
Not covered |
|
Tax-advantaged Account The account you are eligible to use depends on the medical coverage option you enroll in. |
||||||||
|
Health Care FSA |
Health Care FSA |
Health Savings Account with Company contribution:
Limited Purpose Health Care FSA |
Health Care FSA |
|||||
1 For the Consumer Choice Plan, both medical and prescription drug claims apply toward the medical deductible.
2 Out-of-pocket maximum includes the deductible, coinsurance, and all copays.
3 Diagnostic X-ray/lab/tests performed in physician’s office are covered in full after office visit copay.
The way expenses are counted toward the deductible and out-of-pocket maximum work one way for the Core and Buy-Up Plans, and a different way for the Consumer Choice Plan. Understanding these differences can help you decide which plan may pay more toward the care you and your dependents receive, especially if one person is likely to have higher expenses than the rest of the family.
Note: In-network and out-of-network deductibles and out-of-pocket maximums are tracked separately. Only the cost for care received from in-network providers will count toward meeting in-network deductibles and out-of-pocket maximums.
|
Annual Deductible |
Out-of-Pocket Maximum |
||
|---|---|---|---|
|
When the plan begins paying its share of expenses depends on the coverage option you choose and if you cover eligible dependents. |
This is the most you’ll pay during a plan year. Regardless of the medical coverage option you enroll in, when you or a family member reaches the individual out-of-pocket maximum, the plan begins to pay 100% of covered expenses for the remainder of the year for that person. If the total costs by two or more covered family members meet the family out-of-pocket maximum, the plan will begin to pay 100% of covered expenses for the remainder of the year for everyone in your family. Any out-of-pocket expenses used to meet an individual out-of-pocket maximum are also counted toward the family out-of-pocket maximum. |
||
|
Core and Buy-Up Plans If one person meets the individual annual deductible, the plan begins to pay its share of expenses for just that person; the rest of the family must continue to pay for services until the family deductible is met. If two or more family members have costs that combine to meet the family deductible, the plan begins to pay its share of expenses for everyone in your family on the plan. This plan design is called an embedded deductible. |
Consumer Choice Plan Expenses from one or more family members must combine to meet the family annual deductible before the plan begins to pay its share of expenses. This plan design is called a non-embedded deductible. |
||
In-Network Examples
The Core Plan
Juan is enrolled in family coverage in the Core Plan. He covers himself, his wife, Clare, and their daughter, Sarah.
The Consumer Choice Plan
Katrin is enrolled in the Consumer Choice Plan. She covers herself and her two sons, Joseph and Eli.
In partnership with BCBSMA, the Company makes the following benefits available under the Core, Buy-Up, and Consumer Choice Plans to enhance the overall well-being of you and your family:
When enrolled in one of our medical plans, BCBSMA also offers reimbursement of up to $90 for first-time mothers and up to $45 for a refresher class when you participate in a qualified childbirth class.
If you live in California and enroll in the Kaiser HMO, prescription drug coverage is included in your Kaiser HMO plan.
If you enroll in the Core Plan, Buy-Up Plan, or Consumer Choice Plan, prescription drug coverage is provided by Express Scripts and is included in your medical coverage. Express Scripts offers services through a network of retail pharmacies, convenient home delivery and a specialty pharmacy.
Visit Express-Scripts.com to learn more and call Express Scripts at 1-800-396-2256 with any questions.
The amount you pay for each prescription depends on the medical plan you enroll in, whether you fill it at a retail location or through mail-order, and whether it is a generic, brand name, or non-preferred brand name drug. Each year, Express Scripts updates its Preferred Prescription formulary and medications may be added or removed. To review the formulary:
EMD Serono drugs marketed in the U.S. are covered at 100% in BCBSMA medical plans. For the Core and Buy-Up Plans, this means there is no copay. For the Consumer Choice Plan, this means there will be no coinsurance after the applicable deductible has been met. EMD Serono drugs include: Bavencio, Cetrotide, Gonal-F, Gonal-F RFF, Gonal-F RFF Rediject, Mavenclad, Ovidrel, Rebif, Rebif Rebidose, Saizen, Saizen-Saizenprep, Serostim, Tepmetko, Xalkori, and Zorbtive.
This is an exciting way for employees in the U.S. to proudly share in the advantages of being associated with the companies of Merck KGaA, Darmstadt, Germany.
In addition, under all our medical plans, preventive drugs — such as aspirin, folic acid, smoking-cessation drugs, vaccines, and certain others — are covered at 100% with no coinsurance or copay required. They must be prescribed by a physician and in accordance with Express Scripts guidelines.
This chart details the amounts you will pay for different types of medications.
|
Core Plan |
Buy-Up Plan |
Consumer Choice Plan |
Kaiser HMO Plan (California only) |
|
|---|---|---|---|---|
|
You Pay |
||||
|
Preventive prescription drugs1 |
$0 |
$0 |
$0 |
$0 |
|
Retail Prescriptions (30-day supply) |
||||
|
Generic |
$12 copay |
$12 copay |
10% after deductible |
$10 copay |
|
Brand-name |
$30 copay |
$30 copay |
10% after deductible |
$20 copay |
|
Non-preferred brand-name |
$50 copay |
$50 copay |
10% after deductible |
$20 copay |
|
Speciality |
$100 copay |
$100 copay |
10% after deductible |
$20 copay |
|
Mail-Order Prescriptions (90-day supply)2 |
||||
|
Generic |
$30 copay3 |
$30 copay3 |
10% after deductible |
$20 copay |
|
Brand-name |
$70 copay3 |
$70 copay3 |
10% after deductible |
$40 copay |
|
Non-preferred brand-name |
$125 copay3 |
$125 copay3 |
10% after deductible |
$40 copay |
1 Refer here for a list of preventive medications available at no cost.
2 Express Scripts offers a 90-day supply through the mail-order program. In addition, you have access to Walgreens90, a service that allows Walgreens customers the option of having their 90-day prescriptions either mailed to their homes or delivered for pick up from their neighborhood Walgreens.
3 30-day and 60-day supply may be available through mail-order, with lower copays. Please consult the Summaries of Benefits and Coverage for details.
Note
If your doctor prescribes a specialty medication for a serious medical condition, such as Multiple Sclerosis, Rheumatoid Arthritis, or Hepatitis C, your prescriptions will be filled through Accredo®, the Express Scripts specialty pharmacy. Specialty medications not filled by Accredo will not be covered; however, two fills at a retail network pharmacy will be permitted for specialty medications that are of an urgent nature and must be started immediately. If you have an urgent specialty prescription filled at a retail network pharmacy, you will receive a letter from Express Scripts about how to get started with Accredo.
Refer to the Accredo brochure for more information on the specialty pharmacy and see the Save Money on Prescriptions tab for information on an opportunity to save money on expensive specialty prescriptions.
Use Generics
Though their names are different, generic and brand-names drugs are designed to work the same way. In fact, according to the FDA, generic drugs are just as effective as their branded counterparts. And, they typically cost approximately 80% to 85% less.
Talk to your provider about whether you can use a generic drug and save some money.
If your doctor thinks generics aren’t right for you, or they aren’t available, ask about a preferred brand-name drug. You might have higher copayments than with generics, but you’ll still pay less than you would for non-preferred brand-name drugs. For questions about generics, or to see what medicines are preferred by your plan, log in to express-scripts.com or call the number on your member ID card.
Copay Assistance Program for Specialty Medications
Pharmacy benefit experts from PillarRx can help you find copay assistance programs that may be available from drug manufacturers for certain specialty medications, which are complex, expensive prescriptions. If eligible, PillarRx will contact you or your covered dependent over age 18. (PillarRx will contact you regarding any dependents under age 18.)
Order a 90-day Supply of Maintenance Medications
You can save time and money by filling your recurring, long-term maintenance prescriptions through home delivery or using Smart90 Walgreens to pick up in-store. Home delivery medication is ordered in a 90-day supply at a discounted cost. If you choose not to use the home delivery option for your maintenance drugs, you will pay a higher copay for a 30-day supply at a network pharmacy.
Whether you need assistance starting or growing your family or dealing with menopause, we offer resources to help.
The following information details the coverage and resources available to help you navigate your reproductive health journey.
Inflection – including FertilityIQ and MenopauseIQ – makes overwhelming topics easy to understand with approachable, expert-led courses built with you in mind. Proper education can save you money and ease anxiety.
FertilityIQ topics include:
MenopauseIQ topics include:
You’ll have unlimited access to hundreds of online courses and lessons developed and delivered by top fertility, family-building, and menopause experts who help break down complex topics and common concerns. You’ll also find comprehensive reviews of U.S. fertility doctors and clinics by verified patients, searchable by patient age, diagnosis, orientation, ethnicity, and more.
This well-researched, curated resource is here to help you make informed decisions with confidence.
Register for Your Free Membership Today!
Visit benefits4me.inflectioniq.com and use confirmation code Benefits4me and select U.S. as your region.
Once you create your account, use the search bar to find courses and lessons on the topics you’re interested in or explore the “find a doctor” section.
If you have any questions or need assistance, email support@inflectioniq.com
Want a Quick Look at What Inflection Offers?
Check out this webinar recording. (Use passcode: 3jt1e+.X)
Targeted Help for Everyone
Inflection provides dedicated courses for those who identify as Black, Latinx, South Asian, East Asian, unpartnered, cis-lesbian, cis-gay, trans-male, trans-female, and military/veteran populations.
Inflection offers support to ensure we can all be supportive family, friends, and colleagues. Through SensitivityIQ, you’ll find courses on how to talk about difficult topics, including: miscarriage, fertility treatments, LBGTQ+ family building, being childless by circumstance, and cancer and fertility preservation.
You have access to a “You Plus Two” program, which lets you extend two gift memberships to anyone you choose, including family and friends. Share this invitation digitally, at any time, and change who has the membership throughout the year.
We have partnered with Blue Cross Blue Shield of MA to offer fertility services such as egg freezing, harvesting, and preservation benefits to all employees and their enrolled spouses or domestic partners.
Examples of coverage include:
EMD Serono Drugs Are 100% Covered
If you need prescriptions for family planning—or any other reason—and are enrolled in one of our BCBSMA plans, EMD Serono drugs marketed in the US are 100% covered. This means you’ll have a $0 copay for the Core or Buy-Up plans or 0% coinsurance once you reach your deductible for the Consumer Choice plan. EMD Serono drugs include: Bavencio, Cetrotide, Gonal-F, Ovidrel.
Maven offers 24/7 virtual support and guidance to employees enrolled in a Company BCBSMA medical plan and their eligible dependents, for fertility treatment, pregnancy, newborn care, and menopause. You and your partner can meet with providers any time day or night to get the support you need and put your mind at rest.
You and your partner have free, confidential access to Maven’s virtual clinic to:
Begin Using Your Free Membership Today
Download the Maven app:
Or visit: mavenclinic.com/join/bcbsma-asc
You will be prompted to create an account with your personal email and a password of your choosing. If you are prompted to select your employer, choose Benefits4Me. If you are asked to enter your “subscriber ID,” enter the number on your BCBSMA ID card.
After you create your account, choose the track you’re interested in and answer some questions to be connected to the right resources, including an advocate and provider.
If you have any trouble registering, email support@mavenclinic.com for assistance.
Visit My Fertility Story for customized fertility and family planning resources.
Visit our internal Fertility Help Desk any time for assistance with options and next steps.
Visit resolve.org for help understanding resources and guidance. Note: This is a public resource that is not affiliated with the Company.
Refer to this brochure for information on the medical coverage available to help you start or grow your family.
Contact Included Health at 1-833-938-9948 or visit includedhealth.com/Benefits4Me for personalized, hands-on support throughout the process.
Note: The Company also offers:
Did You Know?
The Company will reimburse first-time mothers who are enrolled in a BCBSMA medical plan option through the Benefits4Me program up to $90 for a childbirth class to prepare for the arrival of their new addition. And, after the first child, mothers are eligible for an additional $45 for refresher classes.
Use the Childbirth Class Reimbursement form to request reimbursement.
When you enroll in a Company medical plan through Blue Cross Blue Shield of Massachusetts, you and your covered family age 18+ get access to Virta, a type 2 diabetes program, at no additional cost to you. Note: There are some medical conditions that could exclude patients from Virta support.
Virta is a new type of diabetes and weight-loss care that uses nutrition and technology to help reverse* your condition.
Virta’s personalized nutrition program is designed to meet your lifestyle and needs, so you can lose weight, lower your blood sugar, and transform your health. No calorie counting, no extra gym visits—just small but meaningful changes to what you eat.
You’ll receive:
Start your application today at www.virtahealth.com/join/bcbsma to find out if you qualify.
* Reversal on Virta is defined by reaching an A1c below 6.5% without the use of diabetes medications beyond metformin. Diabetes and related issues can return if lifestyle changes are not maintained.
The Company also offers Wondr weight-loss support.
We are dedicated to providing affordable healthcare coverage for our employees. To ensure our coverage options accurately reflect your needs, we offer four tiers of coverage: Employee Only, Employee + Spouse/Domestic Partner, Employee + Child(ren), and Employee + Family.
The rates below show the cost you will pay for medical and prescription drug coverage per bi-weekly pay period.