Employee and Non-Medicare Benefit Changes Effective July 1

 Health Plan

In-Network Benefit Changes
for other co-pays see individual health plan section

Fallon Community Health Plan Direct Care and Select Care
See additional plan-specific changes below

• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay: Tier 3: $50 retail; $110 mail order
• Mandatory generics implemented

• Specialist office visit copay: $20
• Retail clinic copay: $10

Fallon Community Health Plan Select Care

• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $30
  • *Tier 3: $40
• Retail clinic copay: $15

Harvard Pilgrim Independence Plan

• Specialist office visit copay:
  • **Tier 2: $30
  • *Tier 3: $40
• Emergency Room copay: $75
• Retail clinic copay: $15
• Inpatient hospital copay per admission:
  • Tier 1: $250
  • Tier 2: $500
  • Tier 3: $750
• Outpatient surgery copay per occurrence: $150
• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay:
  • Tier 2: $25 retail; $50 mail order
  • Tier 3: $50 retail; $110 mail order

Health New England

• Primary Care Physician office visit copay – no tiering: $15:
• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $30
  • *Tier 3: $40
• Retail clinic copay: $15
• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay:
  • Tier 2: $25 retail; $50 mail order
  • Tier 3: $50 retail; $110 mail order
• Physical Therapy/Occupational Therapy office visit copay: $20

Navigator by Tufts Health Plan

• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $30
  • *Tier 3: $40
• Emergency Room copay: $75
• Retail clinic copay: $15
• Inpatient hospital copay per admission:
  • Tier 1: $300
  • Tier 2: $700
• Outpatient surgery copay per occurrence: $150
• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay:
  • Tier 2: $25 retail; $50 mail order
  • Tier 3: $50 retail; $110 mail order
• Physical Therapy/Occupational Therapy:  maximum 30 visits per calendar year
• Speech Therapy office visit copay: $15
• Preauthorization required for out-of-network inpatient  and outpatient mental health/substance abuse care

NHP Care (Neighborhood Health Plan)

• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $30
  • *Tier 3: $40
• Retail clinic copay: $15
• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay: tier 3: $50 retail; $110 mail order
• Outpatient mental health/substance abuse office visit copay: $20

UniCare State Indemnity Plan/Basic, Community Choice and PLUS
See additional plan-specific changes below

• Emergency Room copay: $75
• Retail clinic copay: $15
• High-tech imaging copay: $75 (maximum one copay per day)
• Prescription drug copay:
  • Tier 1: $10 retail; $20 mail order
  • Tier 2: $25 retail; $50 mail order
  • Tier 3: $50 retail; $110 mail order
• Specialty drugs up to 30 day supply - implementation of three tier copays:  $10/$25/$50
• Non-sedating antihistamines no longer covered
• Prescription drug value tier eliminated
• Preauthorization required for out-of-network inpatient and outpatient mental health/substance abuse care

UniCare State Indemnity Plan/Basic

• Primary Care Physician office visit copay:
  • **Tier 2: $25
  • *Tier 3: $30
• Specialist office visit copay:
  • ***Tier 1: $15
  • **Tier 2: $25
  • *Tier 3: $35

UniCare State Indemnity Plan/Community Choice

• Primary Care Physician office visit copay:
  • **Tier 2: $25
  • *Tier 3: $30
• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $25
  • *Tier 3: $40
• Inpatient hospital copay per admission: $250

UniCare State Indemnity Plan/PLUS

• Primary Care Physician office visit copay:
  • **Tier 2: $25
  • *Tier 3: $30
• Specialist office visit copay:
  • ***Tier 1: $20
  • **Tier 2: $25
  • *Tier 3: $40
• Inpatient hospital copay per admission:
  • Tier 2: $500
  • Tier 3: $750
• Outpatient surgery copay per occurrence:
  • Tier 2: $100
  • Tier 3: $250