NH HMO LP

Harvard Pilgrim HMO LP

Harvard Pilgrim Best Buy HMO LP offers high-quality coverage at a more affordable premium than a traditional HMO.

●	You’ll choose a primary care provider (PCP).
●	You'll be charged co-payments for office visits.
●	You’ll be subject to an annual deductible.
●	After the deductible services may be subject to coinsurance or a co-pay. (Refer to the Schedule of Benefits).
●	Services provided by Low Cost Providers for Labs and Outpatient Surgical procedures are at a minimal cost.
●	Emergency and Urgent Care services are covered worldwide in accordance with the benefit plan provisions.
●	Prescriptions Drugs have a co-payment 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 (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 $25.00.

Plan Details

HMO LP

Calendar Year Deductible

Individual

$3,000

Family

$6,000

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

Individual

$6,500

Family

$13,000

Lifetime Maximum

Unlimited

Coinsurance / Copays

Preventive Care

100%

Primary Care Physician

$25 Copay

Specialist

$50 Copay

Diagnostics X-Ray and Lab

No Charge

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