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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.
Coinsurance
This is the percentage you may have to pay for a covered service after the deductible is met for self-referred care.
Out-of-Pocket Maximum
This is the most that you could pay during a plan year for deductibles, copayments, and coinsurance for covered services.
The out-of-network out-of-pocket maximum does not protect you from balance billing.
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.
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, or loss of consciousness are examples of a medical emergency. Go directly to the nearest medical facility or call 911 (or the local emergency phone number).
In-Network: copayment applies. This fee is waived if you’re admitted to the hospital or for an observation stay.
Out-of-Network: copayment applies. 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: copayment applies. 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: coinsurance applies.
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: coinsurance applies.
Outpatient Care
Medical and Specialty Office Visits
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Mental Health or Substance Use Treatment
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Chiropractor Office Visits
Up to 18 visits per calendar year.
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Physical and Occupational
Up to 60 visits each per calendar year.
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Diagnostic X-Rays and Lab Tests
In-Network: $0 copayment.
Out-of-Network: coinsurance applies.
CT Scans, MRIs, PET Scans, and Nuclear Cardiac Imaging Tests
In-Network: copayment applies per category of service.
Out-of-Network: coinsurance applies.
Surgery and Related Anesthesia
- Office or health center services: In-Network: copayment applies; Out-of-Network: coinsurance applies.
- Ambulatory surgical facility, hospital outpatient department, or surgical day care unit: In-Network: copayment applies; Out-of-Network: coinsurance applies.
Inpatient Care
General or Chronic Disease Hospital Care
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Mental Health Substance Use Facility Care
In-Network: copayment applies.
Out-of-Network: coinsurance applies.
Prescriptions
You can fill most prescription drugs in two ways:
1. A Participating Pharmacy
Copayment at a participating pharmacy for up to a 30-day supply:
- Tier 1: Most generic drugs - $
- Tier 2: Preferred brand-name drugs - $$
- Tier 3: Non-preferred brand-name drugs - $$$
2. Mail Order Through Express Scripts
Discounted copayments through Express Scripts mail order for a 90-day supply:
- Tier 1: Most generic drugs - $
- Tier 2: Preferred brand-name drugs - $$
- Tier 3: Non-preferred brand-name drugs - $$$
