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2015 Massachusetts Small Employer Group Summaries of Benefits & Coverage (SBCs)

Please note that these are sample SBCs only and they are not specific to any group. If you have any questions, please contact your account manager or representative.

These SBCs are for small group plans effective January 1, 2015 and after. If you need a plan without pediatric dental or a sample with a different 2015 effective date, please contact your sales rep or account rep. Click here for 2014 small employer group SBCs.

  • HMO

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Value $250 Platinum
    $15
    $100
    $250
    $15/$30/$50
    Basic $25 Platinum
    $25
    $125
    $500
    $15/$30/$50
    Advantage $500 Platinum
    $20
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Advantage $1000 Gold
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Advantage $1000 Gold (Low Option)
    $25
    $250
    Covered in full after $1,000 deductible
    $20/$40/$60
    Advantage $1500 Gold
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Advantage $1500 Gold (Low Rx)
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $20/$75/$100;
    Rx Deductible: $250/$500
    Advantage $2000 Gold
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
    Advantage $2000 Gold (Low Option)
    $25
    $250
    Covered in full after $2,000 deductible
    $15/$30/$50
    Advantage $2000 Silver (65%)
    $35
    $2,000 deductible, then 35%
    $2,000 deductible, then 35%
    $20/$75/$100
    Advantage $2000 Silver (80%)
    $30
    $2,000 deductible, then 20%
    $2,000 deductible, then 20%
    $20/$75/$100
    Advantage $3000 Silver
    $30
    $350
    Covered in full after $3,000 deductible
    $20/$50/$75
    Advantage Saver $1500 Gold
    Covered in full after $1,500 deductible; Note: $20 copay applies for routine eye exams only
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $1,500 Deductible, then $15/$30/$50
    Advantage Saver $2000 Silver
    Covered in full after $2,000 deductible; Note: $25 copay applies for routine eye exams only
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $2,000 deductible, then $20/$75/$100

    Your Choice 3-tier HMO

      Tier 1 Tier 2 Tier 3
    Option 9 Gold
    Deductible $250 $1,000 $2,000
    PCP Visit Copay $25 $35 $45
    Specialist visit Copay $35 $45 $55
    ER visit Copay $200 $200 $200
    Inpatient Copay Deductible then $500 Deductible then $750 Deductible then $1,000
      Tier 1 Tier 2 Tier 3
    Option 10 Gold
    Deductible $500 $1,000 $2,000
    PCP Visit Copay $25 $35 $50
    Specialist visit Copay $35 $50 $75
    ER visit Copay $150 $150 $150
    Inpatient Copay Deductible then covered in full Deductible then covered in full Deductible then covered in full

    Your Choice 2-tier HMO

      Tier 1 Tier 2
    Option 8 Gold
    Deductible $750/$1,500
    PCP Visit Copay $25 $50
    Specialist visit Copay $40 $70
    ER visit Copay $200 $200
    Inpatient Copay Deductible then $500 Deductible then $1,000
      Tier 1 Tier 2
    Option 9 Gold
    Deductible $1,000/$2,000
    PCP Visit Copay $25 $50
    Specialist visit Copay $40 $70
    ER visit Copay $150 $150
    Inpatient Copay Deductible Deductible then $1,000
  • PPO

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Basic 25 Platinum
    $25
    $125
    $500
    $15/$30/$50
    Value $250 Platinum
    $15
    $100
    $250
    $15/$30/$50
    Advantage $500 Platinum
    $20
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Advantage $1000 Gold
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Advantage $1500 Gold
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Advantage $2000 Silver (65%)
    $35
    $2,000 deductible then 35%
    $2,000 deductible then 35%
    $20/$75/$100
    Advantage $2000 Silver (80%)
    $30
    $2,000 deductible, then 20%
    $2,000 deductible, then 20%
    $20/$75/$100
    Advantage $2000 Gold
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
    Advantage $3000 Silver
    $30
    $350
    Covered in full after $3,000 deductible
    $25/$50/$75
    Advantage Saver $1500 Gold
    Covered in full after $1,500 deductible; Note: $20 copay applies for routine eye exams only
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $1,500 deductible then $15/$30/$50
    Advantage Saver $2000 Silver Covered in full after $2,000 deductible; Note: $25 copay applies for routine eye exams only
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $2,000 Deductible then $20/$75/$100
  • Select Network Plans

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Select HMO 25 Platinum
    $25 PCP
    $125
    $500
    $15/$30/$50
    Select Advantage HMO 500 Platinum
    $20 PCP
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Select Advantage HMO 1000 Gold
    $20 PCP
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Select Advantage HMO 1500 Gold
    $20 PCP
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Select Advantage HMO 2000 Gold
    $20 PCP
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
  • Steward Community Choice Limited Provider Network Plans

    Plan Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Copay Platinum
    $15
    $150
    $250
    $15/$30/$50
    1000 Gold
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    1500 Gold
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    2000 Gold
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
  • Commonwealth Plans

    Plan Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Commonwealth HMO 25 Platinum
    $25 PCP
    $40 Specialist
    $150
    $500
    $15/$30/$50
    Advantage HMO 400
    w/Coinsurance Gold
    $20 PCP
    $35 Specialist
    30% after $400 deductible
    30% after $400 deductible
    $100 deductible, then $15/50% coinsurance/50% coinsurance
    Advantage HMO 500 Platinum
    $20 PCP
    $35 Specialist
    $100 after $500 deductible
    Covered in full after $500 deductible
    $15/$25/$45
    Commonwealth Advantage HMO 1000 Version 2 Gold
    $30 PCP
    $45 Specialist
    $150 after $1,000 deductible
    $500 after $1,000 deductible
    $20/$30/$50
    Commonwealth Advantage HMO 1500 Gold
    $25 PCP
    $40 Specialist
    $150 after $1,500 deductible
    $250 after $1,500 deductible
    $15/$25/$50
    Advantage HMO 2000
    Version 4 Silver
    $35 PCP
    $60 Specialist
    $350 after $2,000 deductible
    $1,000 after $2,000 deductible
    $25/$50/$75

*|* 11.11.14.02:39