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Advantage Blue

Summary of Benefits Analog Devices, Inc.

This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents effective January 1, 2011, as part of the Massachusetts Health Care Reform Law.

An Association of Independent Blue Cross and Blue Shield Plans

Your Care
Advantage Blue is an exclusive provider health care plan, commonly referred to as an EPO. You receive benefits only when you use preferred providers, except for covered emergency care. After a $500 per admission copayment, you have full coverage for covered inpatient hospital, physician, and other provider covered services. There is a $250 copayment for outpatient surgery at an ambulatory surgical facility, preferred hospital outpatient department, or surgical day care unit. And for certain other outpatient services, you pay a $25 copayment for each visit. Please note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits. If the provider you use is not a preferred provider, you pay all costs even if you are referred by a preferred provider.

Utilization Review Requirements


You must follow the requirements of Utilization Review, which are Pre-Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Home Health Care, and Individual Case Management. Information concerning Utilization Review is detailed in your benefit description. If you need non-emergency or non-maternity hospitalization, you or someone on your behalf must call the number on your ID card for pre-approval. If you do not notify Blue Cross Blue Shield and receive pre-approval, your benefits may be reduced or denied.

Dependent Benefits
This plan covers dependents up to age 26, regardless of the dependents financial dependency, student status, or employment status, unless they are eligible for coverage under a non-parent employer-sponsored plan. Please see your benefit description (and riders, if any) for exact coverage details

How to Find a Preferred Provider


There are several ways to find a preferred provider: Visit the BlueCard Provider Finder website at www.bluecrossma.com/analog. Call the BlueCard Program at 1-800-810-BLUE (2583), 24 hours a day, seven days a week. Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card.

When You Choose Non-Preferred Providers


You are covered for emergency care only. To receive coverage, any necessary follow-up care must be received from a preferred provider.

Emergency Room Services


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 $100 copayment per visit for emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay.

Your Medical Benefits


Plan Specifics Calendar-year deductible Calendar-year out-of-pocket maximum Covered Services Outpatient Care Emergency room visits Allergy injections Clinic visits; physicians and podiatrists office visits Mental health and substance abuse treatment Well-child care exams, including related tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life One visit per calendar year from age 2 through age18 Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Routine GYN exams, including related lab tests (one per calendar year) Routine vision exams (one every calendar year) Routine hearing exams Family planning servicesoffice visits Infertility services (up to $25,000 lifetime benefit maximum, excluding prescription drugs) Chiropractor services (up to 30 visits per calendar year) Short-term rehabilitation therapyphysical and occupational (up to 100 visits per calendar year*) Speech, hearing, and language disorder treatmentspeech therapy Diagnostic X-rays, lab tests, and other tests Oxygen and equipment for its administration Prosthetic devices Home health care and hospice services Durable medical equipment and repairssuch as wheelchairs, crutches, hospital beds (up to $3,000 per calendar year**) Hearing aids for members age 18 or under (up to a $6,000 benefit maximum every 3 years) Surgery and related anesthesia Office setting Ambulatory surgical facility, hospital, or surgical day care unit Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Mental hospital or substance abuse facility care (as many days as medically necessary) Rehabilitation hospital care (up to 60 days per calendar year) Skilled nursing facility care (up to 100 days per calendar year) $100 per visit (waived if admitted or for observation stay) Nothing $25 per visit $25 per visit $25 per visit (no cost for immunizations and routine tests) Your Cost None None

$25 per visit (no cost for immunizations and routine tests) $25 per visit (no cost for routine tests) $25 per visit $25 per visit (no cost for routine tests) $25 per visit $25 per visit and all charges beyond the lifetime maximum $25 per visit $25 per visit $25 per visit Nothing Nothing Nothing Nothing All charges beyond the calendar-year maximum All charges beyond the benefit maximum

Nothing $250 per admission*** $500 per admission*** $500 per admission*** $500 per admission*** $500 per admission***

******* No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care. *** No dollar limit applies when durable medical equipment is furnished as part of covered home dialysis, home health care, or hospice services. *** Copayments for consecutive inpatient admissions (or day surgery followed by inpatient care) within 30 days for the same or related illness will not exceed $500.

Your Medical Benefits (continued)


Covered Services Prescription Drug Benefits At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) Your Cost $10 for Tier 1 $35 for Tier 2 $50 for Tier 3 $20 for Tier 1 $70 for Tier 2 $100 for Tier 3

Healthy Blue Programs


www.livinghealthybabies.com

At Blue Cross Blue Shield of Massachusetts we offer you a group of programs, discounts and savings, resources, and tools to help you get the most you can from your health care plan. Call us at 1-800-225-2019 to receive information that outlines these special programs.
No additional charge $150 per year, per individual/family $150 per year, per individual/family Discount varies Discount varies No additional charge Up to a 30% discount No additional charge A Fitness Benefit toward membership at a health club (see your benefit description for details) Reimbursement for a Blue Cross Blue Shield of Massachusetts designated weight loss program Living Healthy Vision discounts on eyewear (frames, lenses, supplies, and laser vision correction surgery)
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Safe Beginningsdiscounts on home safety items Blue Care LineSM to answer your health care questions 24 hours a daycall 1-888-247-BLUE (2583) Living Healthy Naturally discounts on different types of complementary and alternative medicine services such as acupuncture, massage therapy, nutritional counseling, personal training, Pilates, tai chi, and yoga
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Visit www.AHealthyMe.com for an around-the-clock healthy approach to fitness, family, and fun

Questions? Call 1-800-225-2019.


For questions about Blue Cross Blue Shield of Massachusetts, visit the website at www.bluecrossma.com/analog. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to www.bluecrossma.com/email to sign up.

Limitations and Exclusions. These pages summarize the benefits of your health care plan. The benefit description and riders define the full terms and conditions

in greater detail. Should any questions arise concerning benefits, the benefit descriptions and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. Please note: Blue Cross and Blue Shield of Massachusetts, Inc. administers claims payment only and does not assume financial risk for claims.

Registered Marks of the Blue Cross and Blue Shield Association. SM Service Marks of the Blue Cross and Blue Shield Association. SM Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield HMO Blue, Inc. 2010 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc.

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