Medical
Three plans. Same $4,000 deductible. The real difference is when your cost sharing starts — and that matters more than the sticker price.
What comes out of your paycheck
Apex pays 82.5% of the premium on all three plans. The amounts below are your share, per bi-weekly paycheck, across 26 pay periods.
| Coverage tier | Preferred Blue PPO $4000 Deductible II with HCCS“PPO” | Preferred Blue PPO Saver II $4000“PPO Saver” — HSA-qualified | HMO Blue New England $4000 Deductible with HCCS“HMO” |
|---|---|---|---|
| Employee Only | $73.26 | $63.61 | $65.20 |
| Employee + Spouse | $146.52 | $127.21 | $130.39 |
| Employee + Child(ren) | $135.54 | $117.67 | $120.61 |
| Employee + Family | $227.12 | $197.18 | $202.11 |
The most important difference isn’t the price
On the PPO Saver, your prescriptions sit behind the full deductible
On the PPO and HMO, most office visits and all prescription drugs are covered before you meet your deductible. You pay $15 for a generic from day one.
On the PPO Saver, only in-network preventive and prenatal care come before the deductible. Everything else — including every prescription — means paying the full negotiated price until you have met $4,000. After that, generics are $10.
Blue Cross publishes the same worked example on all three plans. For an identical year of managing type 2 diabetes:
- Cost to you on the PPO
- $1,320
- Cost to you on the HMO
- $1,320
- Cost to you on the PPO Saver
- $4,320
Same care, same year, a $3,000 difference — driven entirely by deductible ordering, not by copay levels. The PPO Saver’s lower drug copays are real, but you only reach them after $4,000.
Who the PPO Saver tends to suit
Employees who use little routine care and few prescriptions, who want the lowest paycheck deduction, and who can absorb the deductible if something happens — plus the Apex HSA contribution and the tax advantages of an HSA.
Who the PPO or HMO tend to suit
Employees who take regular medication, see providers routinely, or want predictable costs from the first visit of the year. Both plans also carry Apex’s larger HRA contribution.
Plan basics
| PPOPPO Tiered | PPO SaverPPO | HMOHMO Tiered | |
|---|---|---|---|
| Deductible and out-of-pocket | |||
| Deductible | $4,000 member$8,000 family | $4,000 member$8,000 family | $4,000 member$8,000 family |
| Out-of-pocket limit — medical | $7,000 member$14,000 family | $6,850 member$13,700 family — this single limit covers everything, including prescriptions | $7,000 member$14,000 family |
| Out-of-pocket limit — prescription drugs | $1,000 member$2,000 family — a separate cap that applies to prescriptions only | No separate limitPrescriptions count toward the single limit above | $1,000 member$2,000 family — a separate cap that applies to prescriptions only |
| Deductible resets | January 1 | January 1 | January 1 |
| Network and access | |||
| Referral needed to see a specialist | No | No | Yes |
| Out-of-network coverage | 20% coinsuranceDeductible applies first | 20% coinsuranceDeductible applies first | Not coveredExcept emergency room, emergency transportation, and urgent care outside the service area |
| Tiered hospital cost sharing | YesYour cost depends on which hospital you use | NoOne in-network cost share | YesYour cost depends on which hospital you use |
| Apex’s contribution | |||
| Employer-funded account | HRA$2,000 employee-only / $4,000 all other tiers | HSA$800 employee-only / $1,600 all other tiers | HRA$2,000 employee-only / $4,000 all other tiers |
| Premium split | 82.5% employer / 17.5% you | 82.5% employer / 17.5% you | 82.5% employer / 17.5% you |
The HRA and HSA are not interchangeable
The HRA is not available on the PPO Saver. The HSA contribution applies to the PPO Saver only. Enrollment is an annual election you generally cannot reverse, so confirm which account comes with your plan before you choose.
What you pay when you use care
In-network, at a lower-cost-share hospital or a non-hospital provider. Amounts apply after the deductible where a deductible applies.
| Service | PPO | PPO Saver | HMO |
|---|---|---|---|
| Seeing a provider | |||
| Primary care visit | $25Before the deductible | $25After the deductible | $25Before the deductible |
| Specialist visit | $40Also $40 for chiropractic and acupuncture | $40After the deductible | $40Referral required |
| Preventive care, screening, immunization | No charge | No chargeCovered before the deductible | No charge |
| First two diabetes-related visits each year | No chargeCost share waived, PCP or specialist | See SBC | No chargeCost share waived, PCP or specialist |
| Tests and imaging | |||
| Diagnostic test — x-ray, blood work | No charge | No chargeDeductible applies first | No charge |
| Imaging — CT, PET, MRI | No charge | No chargeDeductible applies first | No charge |
| Urgent and emergency care | |||
| Urgent care | $40 | $40After the deductible | $40 |
| Emergency room | No chargeDeductible applies first | No chargeDeductible applies first | $500 per visitDeductible does not apply. Copay waived if you are admitted or held for observation |
| Emergency medical transportation | No chargeDeductible applies first | See SBC | No chargeCovered before the deductible |
| Prescription drugs — 30-day retail / 90-day mail | |||
| Generic | $15 retail$30 mail · before the deductible | $10 retail$20 mail · after the $4,000 deductible | $15 retail$30 mail · before the deductible |
| Preferred brand | $30 retail$60 mail · before the deductible | $25 retail$50 mail · after the $4,000 deductible | $30 retail$60 mail · before the deductible |
| Non-preferred brand | $50 retail$150 mail · before the deductible | $45 retail$135 mail · after the $4,000 deductible | $50 retail$150 mail · before the deductible |
| Specialty | Applicable generic, preferred or non-preferred cost shareFrom a designated specialty pharmacy. Not covered out-of-network | Applicable cost shareAfter the deductible. Not covered out-of-network | Applicable cost shareNot covered out-of-network |
Where you go changes what you pay
The PPO and HMO use Hospital Choice Cost Sharing. You pay the lower in-network cost share at most preferred general hospitals, and a higher one at certain preferred general hospitals. A hospital’s tier can change, but no more than once a calendar year.
| Service | Lower-cost-share hospitalor a non-hospital provider | Higher-cost-share hospitalcertain preferred general hospitals |
|---|---|---|
| Hospital stay — facility fee | No charge | $1,000 per admission |
| Outpatient surgery — facility fee | No charge | $1,000 per admissionNo charge at other providers |
| Childbirth and delivery — facility | No charge | $1,000 per admission |
| Diagnostic x-ray and lab tests | No charge | $100 x-ray · $35 labApplies per category of test per day. No charge at other providers |
| Imaging — CT, PET, MRI | No charge | $450No charge at other providers |
| Rehabilitation — outpatient | $40 per visit | $75 per visit$40 at other providers. Limited to 60 outpatient visits per year |
Check your hospital’s tier before a planned procedure
A single admission at a higher-cost-share hospital can cost $1,000 more on the PPO or HMO. Blue Cross publishes the hospital list at bluecrossma.org/hospitalchoice. For anything planned rather than urgent, it is worth two minutes.
Read the full details
The Summary of Benefits and Coverage is the official document for each plan. Where anything on this page differs from the SBC, the SBC governs.
PPO $4000 Deductible II with HCCS
Summary of Benefits and Coverage, effective on or after 01/01/2027.
PPO Saver II $4000
Summary of Benefits and Coverage, HSA-qualified plan.
HMO Blue New England $4000 with HCCS
Summary of Benefits and Coverage, effective on or after 01/01/2027.
Still not sure?
Book a 30-minute session with Jeff to talk through your own situation — what care you actually use, what you take regularly, and what you can absorb if something goes wrong.
Ready to enroll?
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