NH ElevateHealth_HMO

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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.

●	With this plan, you must receive all of your care from ElevateHealth providers and hospitals (except in a medical emergency).
●	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.
●	If you will be covering family members on your policy, each of them can choose different ElevateHealth PCPs.
●	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.
●	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.
●	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.
●	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.
●	Prescription Drug costs are based on a 4 Tier Benefit.
●	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.
●	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) 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