HomeMy Public PortalAboutH P INDEPENDENCE-PLAN Benefits of Summary 2018-2019Summary of Benefits
July 1, 2018 -June 30, 2019
Independence Plans"' POS
In -Network I Out -of -Network*
Deductible $500 per Member / $1,000 per Family
$500 per Member / $1,000 per Family
Out -of -Pocket Maximum $5,000 per Member / $10,000 per Family
All in -network medical, prescription drug and
mental health Copays and Deductibles apply to
the out-of-pocket maximum.)
$5,000 per Member / $10,000 per Family
(excluding Coinsurance for Skilled
Nursing Facility Care)
Outpatient Care
Primary Care Provider Visits
$10/$20/$40
Deductible, then 20% coinsurance
Specialist Visits
Tier 1 Copayment: $30
Tier 2 Copayment: $60
Tier 3 Copayment: $75
Deductible, then 20% coinsurance
Emergency Room Copayment —
waived if admitted
$100 Copayment, then Deductible
$100 Copayment, then Deductible
Mammograms and Pap smears
No charge
Deductible, then 20% coinsurance
Administration of Allergy Injections
Deductible, then no charge
Deductible, then 20% coinsurance
High -Tech Radiology
(e.g., MRI, PET and CT scans)
$100 Copayment per scan, then Deductible
Deductible, then 20% coinsurance
Hospital Services
Inpatient Semi -Private Room and
Board and Physicians' Services
Inpatient copayment:
• Tier 1 = $275
• Tier 2 = $500
• Tier 3 = $1,500
Subject to Hospital Inpatient Copayment,
then Deductible (Limited to one Copayment
per quarter)
Deductible, then 20% coinsurance
Surgical Day Care
$250 Copayment per visit, then Deductible.
(There is a maximum of four Surgical Day Care
Copayments per Member per plan year.)
Deductible, then 20% coinsurance
Hospital Outpatient Services
(e.g., lab tests, anesthesia and X-rays)
Deductible, then no charge
Deductible, then 20% coinsurance
Skilled Nursing Facility Care Services
up to 45 days per plan year
20% of Reasonable Charges (Coinsurance)
after the Deductible has been met
Deductible, then 20% coinsurance
Inpatient Rehabilitation Services
Deductible, then no charge
Deductible, then 20% coinsurance
Prescription Drug Benefit — New for 2018:
The GIC will provide prescription drug coverage through Express Scripts effective July 1.
In -Network Retail Pharmacy —
30 -day supply
Mail Order — 90 -day supply
Deductible: $100 per Member / $200 per Family, then
$10/$30/$65
$25/$75/$165
Other Services
Durable Medical Equipment
including Prosthetics
Deductible, then no charge
Deductible, then 20% coinsurance
Physical and Occupational Therapies
up to 90 consecutive days per
or injury
$20 Copayment
Deductible, then 20% coinsurance
`illness
/
* Please note that non -participating providers may bill you for the differences between their charges and the amount Harvard Pilgrim
pays for covered services.
cyHarvard Pilgrim
Healthcare
continued ►►
Aft Commonwealth of Massachusetts
velni Group Insurance Commission
Summary of Benefits
July 1, 2018 -June 30, 2019
Independence Plans"' POS
In -Network
Out -of -Network*
Other Services (continued)
Chiropractic Care
20 visits per plan year
$20 Copayment
Deductible, then 20% coinsurance
Bi-annual Routine Vision Exam —
covered once every 24 months
A $20 copayment applies when you
have this exam with a participating
optometrist.
Tier 1 Copayment: $30
Tier 2 Copayment: $60
Tier 3 Copayment: $75
Deductible, then 20% coinsurance
Ambulance
Deductible, then no charge
Deductible, then 20% coinsurance
Behavioral Health
Office Visits
Individual: $10 per visit
Group: $15 per visit
Deductible, then 20% coinsurance
Inpatient — General Hospital
(semi -private room and board
and special services)
$275 Copayment per admission (Limited to one
Copayment per quarter)
Deductible, then 20% coinsurance
Inpatient Mental Hospital Facility
$275 Copayment per admission (Limited to one
Copayment per quarter)
Deductible, then 20% coinsurance
Inpatient Substance Abuse Facility
$275 Copayment per admission (Limited to one
Copayment per quarter)
Deductible, then 20% coinsurance
s,
* Please note that non -participating providers may bill you for the differences between their charges and the amount Harvard Pilgrim
pays for covered services.
cyHarvard Pilgrim
Healthcare
ay—
Alft Commonwealth of Massachusetts
nn Group Insurance Commission
cc4264_ind 3_18