Bookmark

2013 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, 2013 and after. If you need an SBC for a plan with an effective date prior to January 1, 2013, please contact your sales rep or account rep, or review the 2012 small employer group SBCs here.

  • HMO Product Sheets

    HMO

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Premium**
    $10
    $100
    None
    $15/$30/$50
    Value
    $15
    $100
    $250
    $15/$30/$50
    Value
    $15
    $100
    $350
    $250/$500 deductible
    $20/$75/$100
    Basic
    $50
    $250
    $1,000
    $250/$500 deductible
    $15/$30/$50
    Basic
    $35
    $150
    $750-Day Surgery
    $1,000-Inpatient Care
    $100/$200 deductible
    $15/$30/$50
    Basic
    $25
    $125
    $600
    $250/$500 deductible
    $20/$75/$100
    Basic
    $25
    $150
    $250-Day Surgery
    $1,000-Inpatient Care
    $15/$30/$50
    Basic
    $25
    $125
    $600
    $15/$30/$50
    Basic
    $20
    $125
    $250-Day Surgery
    $500-Inpatient Care
    $15/$30/$50
    Choice Copay
    $20-PCP
    $40-
    Specialist
    $150
    $250-Community
    $750-Tertiary
    $15/$30/$50
    Advantage
    $20
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $250/$500 deductible
    $20/$75/$100
    Advantage
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $250/$500 deductible
    $20/$75/$100
    Advantage
    $20
    10% coinsurance after $500 deductible
    10% coinsurance after $500 deductible
    $15/$30/$50
    Advantage
    $20
    20% coinsurance after $1,000 deductible
    20% coinsurance after $1,000 deductible
    $15/$30/$50
    Advantage
    $20
    20% coinsurance after $2,000 deductible
    20% coinsurance after $2,000 deductible
    $15/$30/$50
    ** Small Group Premium plans were closed to new business beginning April 1, 2009. Existing groups may remain on the plan and add new members during open enrollment or for qualifying events.
    Your Choice Product Sheet

    Your Choice 3-tier HMO

      Tier 1 Tier 2 Tier 3
    Option 2
    Deductible NA NA NA
    PCP Visit Copay $30 $40 $60
    Specialist visit Copay $40 $50 $75
    ER visit Copay $150 $150 $150
    Inpatient Copay $500 $1,000 $1,500
      Tier 1 Tier 2 Tier 3
    Option 3
    Deductible NA $500/$1,000 $2,000/$4,000
    PCP Visit Copay $15 $25 $45
    Specialist visit Copay $25 $35 $50
    ER visit Copay $100 $100 $100
    Inpatient Copay $150 Deductible then $150 Deductible then $1000
      Tier 1 Tier 2 Tier 3
    Option 6
    Deductible NA $750/$1500 $2,000/$4,000
    PCP Visit Copay $25 $35 $50
    Specialist visit Copay $35 $50 $75
    ER visit Copay $150 $150 $150
    Inpatient Copay $350 Deductible then covered in full Deductible then $1,000
      Tier 1 Tier 2 Tier 3
    Option 7
    Deductible $500/$1,000 $1,000/$2,000 $2,000/$4,000
    PCP Visit Copay $25 $35 $50
    Specialist visit Copay $35 $50 $75
    ER visit Copay $150 $150 $150
    Inpatient Copay Deductible then 10% coinsurance Deductible then 20% coinsurance Deductible then 30% coinsurance
    Your Choice Product Sheet

    Your Choice 2-tier HMO

      Tier 1 Tier 2
    Option 2
    Deductible $500/$1,000
    PCP Visit Copay $20 $50
    Specialist visit Copay $35 $70
    ER visit Copay $150 $150
    Inpatient Copay Deductible then covered in full Deductible then $1,000
      Tier 1 Tier 2
    Option 4
    Deductible NA $2,000/$4,000
    PCP Visit Copay $25 $50
    Specialist visit Copay $35 $75
    ER visit Copay $150 $150
    Inpatient Copay $500 Deductible then $1,000
      Tier 1 Tier 2
    Option 5
    Deductible $1,000/$2,000
    PCP Visit Copay $25 $50
    Specialist visit Copay $40 $70
    ER visit Copay $150 $150
    Inpatient Copay Deductible then covered in full Deductible then $1,000
      Tier 1 Tier 2
    Option 7
    Deductible $2,000/$4,000
    PCP Visit Copay $25 $50
    Specialist visit Copay $35 $75
    ER visit Copay $150 $150
    Inpatient Copay Deductible then 20% coinsurance Deductible then 30% coinsurance
  • PPO Product Sheets

    PPO

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Basic
    $50
    $250
    $1,000
    $250/$500 deductible
    $15/$30/$50
    Basic
    $35
    $150
    $750-Day Surgery
    $1,000-Inpatient Care
    $100/$200 deductible
    $15/$30/$50
    Basic
    $25
    $125
    $600
    $15/$30/$50
    Basic
    $20
    $125
    $250-DaySurgery
    $500-Inpatient Care
    $15/$30/$50
    Value
    $15
    $100
    $250
    $15/$30/$50
    Premium**
    $10
    $100
    None
    $15/$30/$50
    Advantage
    $20
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Advantage
    $20
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
    Advantage
    $20
    10% coinsurance after $500 deductible
    10% coinsurance after $500 deductible
    $15/$30/$50
    Advantage
    $20
    20% coinsurance after $1,000 deductible
    20% coinsurance after $1,000 deductible
    $15/$30/$50
    Advantage
    $20
    20% coinsurance after $2,000 deductible
    20% coinsurance after $2,000 deductible
    $15/$30/$50
    ** Small Group Premium plans were closed to new business beginning April 1, 2009. Existing groups may remain on the plan and add new members during open enrollment or for qualifying events.
    Your Choice Product Sheet

    Your Choice 3-tier PPO

      Tier 1 Tier 2 Tier 3 Out-of-network
    Option 2
    Deductible NA NA NA $1500/$3000
    PCP Visit Copay $30 $40 $60 80% after deductible
    Specialist visit Copay $40 $50 $75 80% after deductible
    ER visit Copay $150 $150 $150 $150
    Inpatient Copay $500 $1000 $1,500 80% after deductible
    Your Choice Product Sheet

    Your Choice 2-tier PPO

      Tier 1 Tier 2 Out-of-network
    Option 5
    Deductible $1,000/$2,000 $1,000/$2,000
    PCP Visit Copay $25 $50 80% after deductible
    Specialist visit Copay $40 $70 80% after deductible
    ER visit Copay $150 $150 $150
    Inpatient Copay Deductible then covered in full Deductible then $1,000 80% after deductible
  • Advantage Saver Product Sheet

    Advantage Saver

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Advantage HMO Saver
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    Deductible, then
    $15/$30/$50
    Advantage HMO Saver
    $25
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    Deductible, then
    $15/$30/$50
    Advantage HMO Saver
    $25
    Covered in full after $2,500 deductible
    Covered in full after $2,500 deductible
    Deductible, then
    $15/$30/$50
    Advantage HMO Saver
    $25
    20% coinsurance after $2,000 deductible
    20% coinsurance after $2,000 deductible
    Deductible, then
    $15/$30/$50
    Advantage PPO Saver
    $20
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    Deductible, then
    $15/$30/$50
    Advantage PPO Saver
    $25
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    Deductible, then
    $15/$30/$50
    Advantage PPO Saver
    $25
    Covered in full after $2,500 deductible
    Covered in full after $2,500 deductible
    Deductible, then
    $15/$30/$50
    Advantage PPO Saver
    $25
    20% coinsurance after $2,000 deductible
    20% coinsurance after $2,000 deductible
    Deductible, then
    $15/$30/$50
  • Select Network Product Sheets

    Select Network Plans

    Level Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Select HMO 20
    $20 PCP
    $125
    $500
    $15/$30/$50
    Select HMO 25
    $25 PCP
    $125
    $600
    $15/$30/$50
    Select Advantage
    HMO 500
    $20 PCP
    Covered in full after $500 deductible
    Covered in full after $500 deductible
    $15/$30/$50
    Select Advantage HMO 1000
    $20 PCP
    Covered in full after $1,000 deductible
    Covered in full after $1,000 deductible
    $15/$30/$50
    Select Advantage HMO 1500
    $20 PCP
    Covered in full after $1,500 deductible
    Covered in full after $1,500 deductible
    $15/$30/$50
    Select Advantage HMO 2000
    $20 PCP
    Covered in full after $2,000 deductible
    Covered in full after $2,000 deductible
    $15/$30/$50
  • Steward Community Choice Product Sheet

    Steward Community Choice Limited Provider Network Plans

    Plan Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    Copay
    $15
    $150
    $250
    $15/$30/$50
    1000
    $20
    Covered in full after deductible
    Covered in full after deductible
    $15/$30/$50
    1500
    $20
    Covered in full after deductible
    Covered in full after deductible
    $15/$30/$50
    2000
    $20
    Covered in full after deductible
    Covered in full after deductible
    $15/$30/$50

  • Commonwealth Plans

    Plan Office Visit Copay ER Copay Hospital Copay Pharmacy Copays
    HMO 20 Version 2
    $20 PCP
    $30 Specialist
    $75
    $150
    $15/$30/$50
    HMO 25
    $25
    $100
    $500
    $15/50%/50%
    Advantage HMO 250
    w/Coinsurance
    $25 PCP
    $40 Specialist
    $150
    35% coinsurance after deductible
    $250/$500 deductible
    for Tier 2 and Tier 3
    Advantage HMO 1000
    $20
    $100 after deductible
    Covered in full after deductible
    $15/$30/$50
    Advantage HMO 2000
    Version 2
    $30 PCP
    $45 Specialist
    $150 after deductible
    $500
    $250/$500 deductible
    for Tier 2 and Tier 3
    Advantage HMO Saver
    $25 after deductible
    $100 after deductible
    20% coinsurance after deductible
    $15/50%/50%

*|* 11.20.12.11:10