NH HSA

Harvard Pilgrim HD HMO HSA

Harvard Pilgrim Best Buy HMO HSA has a lower rate with a higher annual deductible but covers many preventive care services at no charge.

●	You’ll choose a primary care provider (PCP).
●	For most other services you must first satisfy the deductible. After that, you are covered in full.
●	Prescription drugs copays are charged towards your deductible. Co-payment based on a 3 Tier Benefit.
●	Prescription Drugs - 100% covered once deductible is met.
●	This plan allows you to set up a Health Savings Account (HSA) to help you pay your medical costs.
●	This plan allows you to set up a Limited Purpose Flexible Spending Account (FSA) for employees with a HSA. The funds in a Limited Purpose FSA can only be used for qualified expenses related to vision and dental care.
●	Emergency and Urgent Care services are covered worldwide in accordance with the benefit plan provisions.
●	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 HMO HSA

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

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