To meet market demands for products that offer cost-saving incentives to members for selecting high-quality, lower-cost providers, we offer Blue Options tiered network products. Primary care providers and hospitals are grouped into tiers based on cost and nationally accepted measures for quality. The out-of-pocket cost the member pays for care is based on the benefits tier of their primary care provider or acute care hospital. This encourages members to consider the cost and quality each time they get care.
| Benefits tier | Who is included | Member cost |
|---|---|---|
| Enhanced |
|
$ — lowest cost |
| Standard1 |
|
$$ — moderate cost |
| Basic |
|
$$$ — highest cost |
1. In limited circumstances, to increase local access, the Standard Benefits Tier includes certain providers whose scores would put them in the Basic Benefits Tier.
Note: We do not tier specialists or other clinicians and facilities. Primary care providers were measured based on their HMO patients as part of their provider group, and hospitals were measured based on their individual facility performance. Provider groups can be composed of an individual provider, or a number of providers who practice together. Tier placement is based on cost and quality benchmarks where measurable data is available. Providers without sufficient data for either cost or quality are placed in the Standard Benefits Tier. Primary care providers that do not meet benchmarks for one or both of the domains and hospitals that do not meet benchmarks for cost or that use nonstandard reimbursement are placed in the Basic Benefits Tier.
This web site gives general information about our tiered network plan designs. There are currently three tiered Options plan designs called HMO Blue Options, HMO Blue New England Options, and Preferred Blue PPO Options. In our tiered plans, members pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of the provider furnishing the services. A provider's benefits tier may change. Overall changes to the benefits tiers of providers will happen no more than once each calendar year. As each member renews, their benefit will be updated to reflect the change in tiers. For help in finding the benefits tier of a provider, visit Find a Doctor & Estimate Costs and search for the appropriate network.
Use our Find a Doctor & Estimate Costs tool to see the tier of a doctor or acute care hospital. Or, download a copy of our hospital tiering lists to see how individual hospitals are tiered based on the member’s plan design.
Blue Options V.5 Hospital Tiering (effective January 1, 2022)
Blue Options V.5 Hospital Tiering (effective January 1, 2021)
