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Harvard Pilgrim
ElevateHealth High Deductible HMO HSA
Harvard
Pilgrim's
ElevateHealth
High Deductible HMO
HSA
offers
high-quality
coverage
using a select network of New Hampshire's leading health
professionals and hospitals
at a
more
affordable
premium
than
a traditional
HMO.
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With this plan, you must receive
all of your care from ElevateHealth providers and hospitals
(except in a medical emergency). |
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You will be required to choose a
primary care provider (PCP) from the ElevateHealth network to
handle your care and give you referrals to specialists. |
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If you will be covering family
members on your policy, each of them can choose different
ElevateHealth PCPs. |
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You can get acupuncture,
chiropractic care, routine eye exams and most kinds of
gynecological care without your PCP's referral, but you must see
ElevateHealth providers for these services. |
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In the unlikely event that an
ElevateHealth provider or hospital cannot provide the care you
need, your doctor can ask Harvard Pilgrim for authorization to
send you outside the ElevateHealth network. |
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In a medical emergency (e.g.,
heart attach, stroke, choking, loss of consciousness or
seizures), call 911 or go to the nearest emergency room. Once
you are out of the hospital, be sure to follow up with your PCP
for any additional care you may need. |
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You have coverage for unexpected
or unforeseen urgent care (e.g., earach, flu or sprain) when
you're traveling. Otherwise, you must receive care from
ElevateHealth providers and hospitals. |
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Prescription
Drug
costs are
based
on
a
4
Tier
Benefit. |
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The ElevateHealth HSA HMO
has a broader range of services that fall under the
annual deductible, and you are able to open a health
savings account (HSA) to help pay for qualified health
care expenses. |
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This plan offers
Care Management Services in partnership with
Benevera Health. |
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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. |
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Under this plan your DoD (including Optum) co-pay is
$0.00. |
Plan Details
|
ElevateHealth HMO |
Calendar
Year
Deductible |
Individual |
$3,000 |
Family |
$6,000 |
Calendar
Year
Out-of-Pocket
Maximum
(Out-of-Pocket
Maximum
Includes
Deductible) |
Individual |
$3,000 |
Family |
$6,000 |
Lifetime
Maximum |
Unlimited |
Coinsurance
/
Copays |
Preventive
Care |
100% |
Primary
Care
Physician |
Deductible,
then no charge |
Specialist |
Deductible,
then no charge |
Diagnostics X-Ray and Lab |
Deductible,
then no charge |
Urgent
Care
–
Convenience
Clinic
–
Urgent
Care
Clinic
–
Hospital
Urgent
Care |
Deductible,
then no charge
Deductible,
then no charge
Deductible,
then no charge |
Emergency
Room |
Deductible, then no charge |
Inpatient
Hospital
Care |
Deductible, then no charge |
Outpatient
Surgery |
Deductible,
then no charge
|
Pharmacy |
Retail
RX
(up
to
30-day
supply) |
Tier
1 |
Deductible,
then no charge |
Tier
2 |
Deductible,
then no charge |
Tier
3 |
Deductible,
then no charge |
Tier
4 |
Deductible,
then no charge |
Mail
Order
RX
(up
to
90-day
supply) |
Tier
1 |
Deductible,
then no charge |
Tier
2 |
Deductible,
then no charge |
Tier
3 |
Deductible,
then no charge |
Tier
4 |
Deductible,
then no charge |
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Rates
2021 NH Staff/Center Faculty (12 mos) 2021
NH Staff (10 mos)
2021 RFF (12mos/8mos)
Other Tools
ElevateHealth Flyer
![](../../New/Benefits/Benefit%20Docs/DoD-Logo.JPG)
![](../../New/Benefits/Optum.logo.JPG)
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:
![](NH-Ele1.gif)
(833)333-4742
www.harvardpilgrim.org
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