AZ PPO LP

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Harvard Pilgrim PPO LP

Harvard Pilgrim PPO LP offers choice, flexibility and high-quality coverage at a more affordable premium than a traditional PPO.

●	You are not required to have a primary care provider (PCP) or get referrals for care, and you will be able to receive care from almost any doctor or hospital across the nation using the United Healthcare Network of providers.
●	You’ll be subject to an annual deductible.
●	After the deductible services may be subject to coinsurance or a copay.
●	Emergency and Urgent Care services are covered worldwide in accordance with the benefit plan provisions.
●	Prescription drugs have a copayment based on a 4 Tier Benefit .
●	This plan allows you to have a Medical Flexible Spending Account (FSA).
●	This plan offers Care Management Services in partnership with Benevera Health.
●	All members have access to telemedicine visits through Doctor on Demand (DoD) and Optum. DoD provides treatment for 90% of the most common health conditions affecting the mind and body.
●	Under this plan your DoD (including Optum) copay is $25.00.

Plan Details

PPO LP

Calendar Year Deductible

Individual

$3,000

Family

$9,000

Calendar Year Out-of-Pocket Maximum (Out-of-Pocket Maximum Includes Deductible)

Individual

$6,500

Family

$13,000

Lifetime Maximum

Unlimited

Coinsurance / Copays (In-Network Providers)

Preventive Care

100%

Primary Care Physician

$25 Copay

Specialist

Level 1: $25/Level 2: $50

Diagnostics X-Ray and Lab

100% after deductible

(Labs covered at 100% at Select LP Providers)

Urgent Care

– Convenience Clinic

– Urgent Care Clinic

– Hospital Urgent Care

$25 Copay

$50 Copay

$75 after deductible

Emergency Room

$250 after deductible

(waived if admitted)

Inpatient Hospital Care

100% after deductible

Outpatient Surgery

100% after deductible

($100 for Select LP Providers)

Pharmacy

Retail RX (up to 30-day supply)

Tier 1

$5

Tier 2

$15

Tier 3

$30

Tier 4

$50

Mail Order RX (up to 90-day supply)

Tier 1

$10

Tier 2

$30

Tier 3

$60

Tier 4

$150