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Harvard Pilgrim HD PPO HSA

There are two levels of coverage: In-Network and Out-of-Network. In-Network coverage applies when you use a Plan Provider for Covered Benefits. Out-of-Network coverage applies when you use a Non-Plan Provider for Covered Benefits.

 

The High Deductible PPO HSA has significant annual deductible, but offers extensive freedom of choice and allows you to set up a Health Saving Account (HSA) to help offset your medical cost.

You are not required to have a primary care provider or get referrals for care.

Certain preventive tests and services are covered at no charge (in-network) or with co-insurance (out-of-network).

You can receive care from almost any doctor or hospital; New Hampshire, Boston or across the nation using the United Healthcare Network providers.

Emergency and Urgent Care services are covered worldwide in accordance with the benefit plan provisions.

This plan allows you to set up a Limited Purpose FSA (LPFSA) for employees with a HSA. The funds in a Limited Purpose FSA (LPFSA) can only be used for qualified expenses related to vision and dental care.

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 (Behavioral Health Providers). 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 $49.00.

Plan  Details

High Deductible PPO HSA

 

In-Network

Out-of-Network

Payment Basis

Neg Fee

UCR Based on Contracted Rates

Life Time Maximum

Unlimited

Unlimited

Calendar Year Deductible

Embedded

Embedded

Individual / Family

$3,000 / $6,000

$6,000 / $12,000

Out-of-Pocket Maximum

Individual / Family

$3,000 / $6,000

$10,000 / $20,000

Employer HSA Seeding

Individual / Family

$1,000 / $2,000

$1,000 / $2,000

Physician Services

  Primary Care Physician

0% after CYD*

20% after CYD*

  Specialist

0% after CYD*

20% after CYD*

Hospital Services

  Inpatient Hospitalization

0% after CYD*

20% after CYD*

  Outpatient Surgery

0% after CYD*

20% after CYD*

  Emergency Room

0% after CYD*

0% after CYD*

Diagnostic Laboratory & X-Ray

  At Physician's Office

0% after CYD*

20% after CYD*

  Advanced Radiology

0% after CYD*

20% after CYD*

Durable Medical Equipment

 

0% after CYD*

20% after CYD*

Pharmacy

Retail RX (up to 30-day supply)

  Generic

0% after CYD*

0% after CYD*

  Brand Name

0% after CYD*

0% after CYD*

  Non-Formulary

0% after CYD*

0% after CYD*

  Specialty Drugs

N/A

N/A

Mail Order RX (up to 90-day supply)

  Generic

0% after CYD*

0% after CYD*

  Brand Name

0% after CYD*

0% after CYD*

  Non-Formulary

0% after CYD*

0% after CYD*

  Specialty Drugs

N/A

N/A

Rates

Arizona Faculty/Staff

Other Tools

 

For Detailed Plan Documents refer to the links below:

Schedule of Benefits

Summary of Benefits and Coverage

Visit the Harvard Pilgrim Site for additional information:

(833)333-4742

www.harvardpilgrim.org

 

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40 University Drive
Rindge, New Hampshire 03461