AZ PPO HSA

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.
●	Prescription drugs copays are charged towards your deductible. Co-payment based on a 3 Tier Benefit.
●	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	$500 / $1,000	$500 / $1,000
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