Covered Services
Routine Physicals
Routine physical exams are covered according to the following schedule:
For children:
- Six visits per year (0–12 months)
- Three visits per year (12–24 months)
- One visit per year (2–18 years)
For adults:
One physical exam is covered each calendar year. Includes an annual mental health wellness exam.
Waiver of Copayment
In-network routine physicals are covered 100% with no copayment.
Out-of-network preventive care is covered 70% after the deductible.
Mental Health Wellness Exam
As of March 31, 2024, Blue Cross covers an annual mental health wellness exam. This exam may be conducted as part of the annual preventive visit with a primary care provider (PCP), or as a standalone visit with a PCP or licensed mental health professional. Because the mental health wellness exam is considered preventive care, there is no out-of-pocket cost for members in most plans.
The annual mental health exam is covered as required by the Act Addressing Barriers to Care (ABC Act) to improve mental health care across Massachusetts.
The exam will consist of taking the patient’s mental health history, a mental health exam and appropriate screening tests, shared decision making (that could include lifestyle education and counseling), and a discussion about next steps. This may include referrals for treatments and medication options. The mental health wellness exam may or may not result in a diagnosis. The exam may be administered by a PCP, including OB/GYNs, licensed mental health professional as part of the annual wellness visit or as a separate exam.
Applied Behavior Analysis
Applied Behavior Analysis (ABA) benefits for children with autism syndrome are expanded to cover dependent children over the age of seven. ABA is covered for dependent children from their third birthday if they have been diagnosed with an Autism Spectrum Disorder. Visits are covered with $35 copayment for in-network services or 70% after deductible for out-of-network services.
Emergency Coverage
The BCBS PPO provides benefits for emergency medical services whether you are in or outside of Massachusetts. These emergency medical services may include inpatient or outpatient services by providers qualified to furnish emergency medical care and that are needed to evaluate or stabilize your emergency medical condition.
In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). You pay a $150 copayment for in-network or out-of-network emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. The out-of-network deductible does not apply.
Within the Enrollment Area
You will receive full coverage after a $150 copayment per person per visit for hospital emergency room treatment you receive at a hospital in the plan network. This copayment will be waived, however, if you are immediately admitted to the hospital.
Outside the Enrollment Area
When you are temporarily outside the enrollment area, the BCBS PPO will cover emergency room treatment in full after a $150 copayment if the illness or injury is sudden and life-threatening. Emergency treatment received at a physician’s office outside the enrollment area will be covered in full after a $35 copayment per person per visit.
Home Health Care Benefits
The BCBS PPO pays benefits for medically necessary home care services and supplies, such as intermittent skilled nursing care and physical therapy, at 100% when you use a participating provider, and at 80% (after the deductible when you use an out-of-network provider).
Coverage is also provided for the following services when determined to be a medically necessary component of the intermittent skilled nursing care or physical therapy:
- Occupational therapy
- Speech therapy
- Medical social work
- Nutritional consultation
- Home health aide
- Durable medical equipment
Prescription Drug Benefits
As a member of the Boston University Health Plan, you will automatically be enrolled in the OptumRx Prescription Drug Coverage. Learn more about your prescription drug coverage.
Mental Health and Substance Abuse Benefits
The BCBS PPO will pay benefits for inpatient and outpatient treatment of mental health and substance abuse.
| Mental Health and Substance Abuse Benefits | ||
|---|---|---|
| Mental Health | BCBS PPO Network | Out-of-Network |
| Inpatient admissions to a licensed general hospital | Covered in full | Covered at 70% after deductible |
| Inpatient admissions to a mental health facility | Covered in full | Covered at 70% after deductible |
| Outpatient services | $35 copayment per visit | Covered at 70% after deductible |
| Substance Abuse | ||
| Inpatient admissions | Covered in full | Covered at 70% after deductible |
| Outpatient services | $35 copayment per visit |
Covered at 70% after deductible |
| Detoxification for drug/alcoholism | Covered in full | Covered at 70% after deductible |