Provider Summary of Benefits and Coverage

Provider Benefits List

The following is a list of the provider summary of benefits documents available to you on this site.

Summary of Benefits and Coverage

Blue Care Elect Preferred (PPO)
Blue Choice New England 2 (Tier 1 Plan POS)
Network Blue New England Options v.5 (Tier 2 Plan Managed Tiered)

The Plan is composed of the following benefits:

Attachment #1
BCBS Blue Choice NE PLAN 2 Schedule of Benefits
Plan Information for 2024

Attachment #2
BCBS Blue Care Elect Schedule of Benefits
Plan Information for 2024

Attachment #3
BCBS Network Blue NE Options v.5 Schedule of Benefits
Plan Information for 2024

Attachment #4
Dental Blue Freedom – Active Plan

Attachment #5
Dental Blue Freedom – Retiree

Attachment #6
Davis Vision

Exhibit B
Medical Claims & Appeals

Life Insurance

Symetra – Full Time Benefit Plan
Symetra – Part Time Benefit Plan

Blue Cross Blue Shield – Pharmacy Benefit Handbook
Handbook Information for 2024

Prescription Drug Benefit

Coverage Changes to BCBSMA Medical and Pharmacy Benefit
Summary of Material Modifications
Blue Cross Blue Shield Pharmacy Benefit Handbook (January 1, 2022)

NOTE: For Envision Benefits, please consult with the SMM dated October 30, 2014, where effective January 1, 2015. Pharmacy Benefits will now be administered by BCBS MA for BCBS members

Envision RX Benefit
Envision RX Benefit Formulary Change Notice

HIPAA Notice of Privacy Practice