HomeMy Public PortalAboutH P Primary Choice SBC 2018-2019cyHarvard Pilgrim
Health Care
the Harvard Pilgrim Primary Choice HMO
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered
Services
Massachusetts
Coverage Period: 07/01/2018 — 06/30/2019
Coverage for: Individual + Family I Plan Type: HMO
A
Im• •rt•nt 'u•sti•ns
The Summary of Benefits and Coverage (SBC) document will help
and the plan would share the cost for covered health care services.
you choose a health plan. The SBC shows you how you
NOTE: Information about the cost of this plan (called
the premium) will be provided separately. This is only a summary.
of the complete terms of coverage, www.harvardpilgrim.org. For general
balance billing, coinsurance, copayment, deductible, provider, or
For more information about your coverage, or to get a copy
definitions of common terms, such as allowed amount,
other underlined terms see the Glossary. You can view the
request a copy.
Why this m.tt•rs
Glossary at
www.harvardpilgrim.org/fhcr or call 1-888-333-4742 to
What is the
deductible?
overall
$400 member / $800 family
Generally you must pay all the costs up to the deductible amount
before this plan begins to pay. If you have other family members
on the plan, each family member must meet their own individual
deductible until the total amount of deductible expenses paid
by all family members meets the overall family deductible.
Are there services
covered before you
meet your deductible?
Yes. Preventive care, provider office visits, mental
This plan covers some items and services even if you haven't yet
health, rehabilitation services, and habilitation
met the deductible amount. But, a copayment or coinsurance
services are covered before you meet your deductible.
may apply.
Are there other
deductibles for
specific
Yes. Prescription Drug Deductible: $100 member /
$200 family
There are no other specific deductibles.
You must pay all of the costs for these services up to the specific
deductible amount before this plan begins to pay for these
services?
services.
What is the
out—of—pocket limit
$5,000 member / $10,000 family
The out-of-pocket limit is the most you could pay in a year of
covered services. If you have other family members in this plan,
for this plan?
they have to meet their own out-of-pocket limit until family
out-of-pocket limit has been met.
MD0000004772, RX0000014666
Page 1 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Important Questions
Answers
y this matters
What is not included in
the out—of—pocket limit?
Premiums, balance -billed charges, and health care this
plan doesn't cover.
Even though you pay these expenses, they don't count toward
the out—of—pocket limit.
Will you pay less if you
use a network provider?
Yes. See www.providerlookuponline.com/
harvardpilgrim/po7/Search.aspx or call
1-888-333-4742 for a list of preferred providers.
This
use
you
bill
charge
your
for
before
plan uses a provider network. You will pay less if you
a provider in the plan's network. You will pay the most if
use an out -of -network provider, and you might receive a
from a provider for the difference
between the provider's
(balance -billing). Be aware,
and what your plan pays
network provider might use an out -of -network provider
some services (such as lab work).
you get services.
Check with your provider
Do you need
see a specialist?
a referral to
Yes, some exceptions apply.
This
for
see
plan will pay some or all of the costs to see a specialist
covered services but only if
the specialist.
you have a referral before you
ommon
Event
If you visit a
provider's office
Copayments and coinsurance cost shown in
this chart are both before
What
Network Provider
(You will pay the least)
$20 copay/ visit;
and
You
after your deductible has been met, if a deductible applies.
Medical
health care
or clinic
Services You May Need
Primary care visit to treat an
injury or illness
Will Pay
Out -of -Network
Provider
(You will pay the most)
Not covered
Limitations, Exception , -
Other Important Information
None
deductible does not
apply
Specialist visit
Level 1: $30 copay/ visit;
Not covered
None
deductible does not apply
Level 2: $60 copay/ visit;
deductible does not apply
Preventive care/screening/
No charge; deductible
Not covered
None
immunization
does not apply
If you have a test
Diagnostic test (x-ray, blood
No charge
Not covered
None
work)
Imaging (CT/PET scans,
MRIs)
$100 copay/ scan
Not covered
Participating Providers limited
to a maximum of one copay/
Member/ day.
Page 2 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
ommon Medical
Event
Services You May Need
What You Will Pay
Limitations, Exceptions,
Other Important Information
Network Provider
(You will pay the least)
Out -of -Network
Provider
(You will pay the most)
If you need drugs to treat
your illness or condition
More information about
prescription drug
Generic drugs
Retail: $10 copay after deductible
Prescription drug coverage is
administered by Express Scripts.
For additional information, visit
www.express-scripts.com/
gicrx or call Customer Service
at 1-855-283-7679 (TTY 711).
Retail cost share is for up to
a 30 day supply; mail order
cost share is for up to a
90 -day supply. Some drugs
require prior authorization
to be covered. Some drugs
have quantity limitations. A
90 -day supply of maintenance
medications may be obtained
at a CVS Pharmacy for the
applicable mail order copay. If
a drug has a generic equivalent,
and you buy the brand name
(even if your physician indicates
no substitutions), you will pay
the generic -level copay plus
the cost difference between the
generic and the brand name
drug.
Maintenance 90/Mail Order:
deductible
$25 copay after
Preferred brand drugs
Retail: $30 copay after deductible
coverage is available
Maintenance 90/Mail Order:
deductible
$75 copay after
at
www express-
scripts.com/gicrx.
Non -preferred brand drugs
Retail: $65 copay after deductible
Maintenance 90/Mail Order:
deductible
$165 copay after
Specialty drugs
Limited to a 30 -day supply with appropriate tier copay
(see above) when purchased at a designated specialty
pharmacy
Must be obtained at a designated
specialty pharmacy. Some drugs
require prior authorization to
be covered. Some drugs have
quantity limitations. Some
specialty drugs may also be
covered under your medical
benefit.
Page 3 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
ommon Medical
Event
Services You May Need
What You Will Pay
Out -of -Network
Network Provider Provider
(You will pay the least) (You will pay the most)
Limitations, Exceptions,
Other Important Information
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
$250 copay/ visit
Not covered
Up to four Surgical Day Care
Copays/ member/ year.
Physician/surgeon fees
No charge
Not covered
None
If you need immediate
medical attention
Emergency room care
$100 copay/ visit
None
Emergency medical
No charge
None
transportation
Urgent care
Convenience care
clinic: $10 copay/ visit;
Convenience care
clinic: $10 copay/ visit;
None
deductible does not apply
deductible does not apply
Urgent care clinic
(including hospital
urgent care clinic): $20
copay/ visit; deductible
Urgent care clinic
(including hospital
urgent care clinic): $20
copay/ visit; deductible
does not apply
does not apply
If you have a hospital
stay
Facility fee (e.g., hospital
room)
Tier 1: $275 copay/
Not covered
Up to one Medical or Mental
Health & Substance Abuse
Hospital Inpatient Copay/
admit
Tier 2: $500 copay/
admit
Member each Quarter.
Physician/surgeon fee
No charge
Not covered
None
If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services
$20 copay/ visit;
Not covered
None
deductible does not
apply
Inpatient services
$275 copay/ admit;
Not covered
Up to one Medical or Mental
Health & Substance Abuse
Hospital Inpatient Copay/
deductible does not
apply
Member each Quarter.
Page 4 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
ommon Medical
Event
Services You May Need
What You
Network Provider
(You will pay the least)
Will Pay
Out -of -Network
Provider
(You will pay the most)
Limitations, Exceptions,
Other Important Information
If you are pregnant
Office visits
$20 copay/ visit;
Not covered
Cost sharing does not apply for
deductible does not
preventive services. Maternity
apply
care may include tests and
services described elsewhere in
the SBC (i.e. ultrasound.)
Childbirth/delivery
professional services
No charge
Not covered
Cost sharing does not apply for
preventive services. Maternity
Childbirth/delivery facility
services
Tier 1: $275 copay/
Not covered
care may include tests and
services described elsewhere in
the SBC (i.e. ultrasound.)
Up to one Medical or Mental
Health & Substance Abuse
Hospital Inpatient Copay/
admit
Tier 2: $500 copay/
admit
Member each Quarter.
If you need help
recovering or have other
special health needs
Home health care
No charge
Not covered
None
Rehabilitation services
Physical &
Occupational Therapy:
$20 copay/ visit;
Not covered
Physical & Occupational
Therapy — 90 consecutive days/
illness or injury
deductible does not
apply
Speech Therapy: No
charge; deductible does
not apply
Habilitation services
Physical &
Occupational Therapy:
$20 copay/ visit;
Not covered
deductible does not
apply
Speech Therapy: No
charge; deductible does
not apply
Skilled nursing care
20% coinsurance
Not covered
— 45 days/ year
Page 5 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
ommon Medical
Event
Services You May Need
What You
Will Pay
Limitations, Exceptions,
Other Important Information
Network Provider
(You will pay the least)
Out -of -Network
Provider
(You will pay the most)
Durable medical equipment
No charge
Not covered
None
Hospice services
No charge
Not covered
For inpatient services, see "If
you have a hospital stay".
If your child needs
dental or eye care
Children's eye exam
Optometrist: $20 copay/
Not covered
— 1 exam every 24 months
visit; deductible does not
apply
Ophthalmologists:
Level 1: $30 copay/
visit; deductible does not
apply
Level 2: $60 copay/
visit; deductible does not
apply
Children's glasses
Not covered
None
Children's dental check-up
Not covered
None
Excluded Services & Other Covered Services:
Services Your Plan Generally
Does NOT Cover (Check your
policy or plan document
for more information and
a list of any other excluded
services.)
• Acupuncture
• Long -Term (Custodial) Care
• Most Cosmetic Surgery
• Most Dental Care (Adult)
• Non -emergency care when traveling outside
the U.S.
• Private -duty nursing
• Routine foot care
• Services that are not Medically Necessary
• Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
• Bariatric surgery
• Chiropractic Care - 20 visits/ year
• Hearing Aids - $2,000/ hearing aid every 24
months/ impaired ear up to age 22
• Hearing Aids - up to $1,700 every 2 years for
age 22 or older
• Infertility Treatment - 5 cycles advanced
reproductive technology/ lifetime
• Routine eye care (Adult) - 1 exam every 24
months
Page 6 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of
Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at
1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage
through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal.
For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact:
HPHC Member Appeals -Member
Services Department
Harvard Pilgrim Health Care, Inc.
1600 Crown Colony Drive
Quincy, MA 02169
Telephone: 1-888-333-4742
Fax: 1-617-509-3085
Department of Labor's Employee
Benefits Security Administration
1-866-444-3272
www.dol.gov/ebsa/healthreform
Health Care for All
30 Winter Street, Suite 1004
Boston, MA 02108
1-800-272-4232
http://www.hcfama.org/helpline
Does this plan provide Minimum Essential Coverage? Yes
If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an
exemption from the requirement that you have health coverage for that month.
Does this Coverage Meet the Minimum Value Standard? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the
Marketplace.
Language Access Services:
Para obtener asistencia en Espanol. llame al 1-888-333-4742.
t0 N 3Z EOM @i1, i n- - 1-888-333-4742.
De assistencia em Portugues, por favor ligue 1-888-333-4742.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Page 7 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductible, copayment and coinsurance) and excluded services under the plan. Use this information to compare the
portion of costs you might pay under different health plans. Please note these coverage examples are based on self -only coverage.
Peg is Having a Baby
(9 months of in -network pre -natal care and a
hospital delivery)
• The plan's overall
deductible
• Specialist copayment
• Hospital (facility)
copayment
• Other copayment
Managing Joe's type 2 Diabetes
(a year of routine in -network care of a
well -controlled condition)
$500 • The plan's overall
deductible
$30 • Specialist copayment
$275 • Hospital (facility)
copayment
$0 • Other copayment
This EXAMPLE event includes services
like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost $12,731
In this example, Peg would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
$500
$280
$0
What isn't covered
Limits or exclusions
Mia's Simple Fracture
(in -network emergency room visit and follow
up care)
$500 • The plan's overall
deductible
$30 • Specialist copayment
$275 • Hospital (facility)
copayment
$0 • Other copayment
This EXAMPLE event includes services
like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost $7,389
In this example, Joe would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
$320
$1,620
$0
What isn't covered
$0 Limits or exclusions
The total Peg would pay $780
is
$500
$30
$275
$0
This EXAMPLE event includes services
like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost $1,925
In this example, Mia would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
$400
$120
$0
What isn't covered
$30 Limits or exclusions
The total Joe would pay is $1,970
$0
The total Mia would pay is $520
The plan would be responsible for the other costs of these EXAMPLE covered services.
Page 8 of 8
Language Assistance Services
Espanol (Spanish) ATENCI6N: Si usted habia espanol, servicios de asistencia Iinguistica, de forma gratuita,
estan a su disposicion. Llame al 1-888-333-4742 (TTY: 711).
Portugues (Portuguese) ATEKAO: Se voce fala portugues, encontram-se disponiveis serviryos Iinguisticos
gratuitos. Ligue para 1-888-333-4742 (TTY: 711).
Kreyol Ayisyen (French Creole) ATANSYON: Si nou pale Kreybl Ayisyen, gen asistans pou sevis ki disponib nan
lang nou pou gratis. Rele 1-888-333-4742 (TTY: 711).
211111:11C(Traditional Chinese) 5cg, : to 1 itJTI IGp , 1 7L;(9 14,111 #-YORE . Mkt 1-
888-333-4742 ( TTY : 711 )
Tieng ViOt (Vietnamese) CH1 Y: Neuu qui vi not Ting Viet, dich Al thong dich cua chung toi san sang phuc Vita
qui vi mien phi. Gqi s6 1-888-333-4742 (TTY: 711).
PyCCKNN (Russian) BHNMAHNE: SCAN Bbl roBopNTe Ha pyCCKOM fi3blKe, TO BaM 4OCrynHbl 6ecnnaTHble ycnyrw
nepeBo4a. 3BOHHTe 1-888-333-4742 (TeneraHn: 711).
4x.ii (Arabic)
1 888-333-4742 cSlc• cl.4.1! Ut .+11'oJ9yie: Ul is1•4•4: _tali iAli rLS� ,Iii :0146.4
(TTY: 71 1 )
I?-1(Cambodian) t fi75st:zdi = tux m§tznturTit,nier, ttuEnstrvttmvumr.pri w
i; ivy 1 ur srcvc� 1-888-333-4742 (TTY: 711)1
N V V G
Francais (French) ATTENTION: Si vous parlez frangais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-888-333-4742 (ATS: 711).
Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia I'italiano, sono disponibili servizi di assistenza
Iinguistica gratuiti. Chiamare it numero 1-888-333-4742 (TTY: 711).
(Continued)
q'#I (orean)'g :Lq-al AfgtEAl� T, i XI hidl�z T 01 75Ez ÷L ! LIcF-1-
888-333-4742 (TTY: 711) i `1 E off T X 12.
E]LTir1vLKcc (Greek) IIPO OXH: Av ehhrlvucct, unctpxouv nrr Sror6carj ocrc Scopcccv urrripEcifc yX corKr1c
undo-njPL rl(. Kantor€ 1-888-333-4742 (TTY: 711).
Polski (Polish) UWAGA: Jeieli mowisz po polsku, moiesz skorzystacz bezplatnej pomocy jgzykowej. 2adzwori
pod numer 1-888-333-4742 (TTY: 711).
iWet (Hindi) t ia-1 3 3 �7 t 3-T' -f E I?Icii I1f-d
1-888-333-4742 (TTY: 711)
o,1° ?trO. (Gujarati) kUUat 41t i : Q (14 3raR1c{t k -toil �Z cif 11 311 (11.04.1 -51.4 J. 1 c -1 al l ci
GtJC4 t . CaRti ut( -ft CITY. T'Y' ^ f 11
tar} '}e9O (Lao) kiog u. fj')OI tJi c8-itJYz`) Y)O, mUt 57)1u O)CU O.nit,J')z'), kmC. 05.361,
ltns 1-888-333.4742 (TTY: 711).
ATTENTION: if you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-888-333-4742 CITY: 711).
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut,
Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
(Continued)
General Notice About Nondiscrimination and Accessibility Requirements
Harvard Pilgrim Health Care and its affiliates as noted below ("HPHC") comply with applicable federal dvil rights laws and
does not discriminate on the basis of race, color, national origin, age, disability, or sex. HPHC does not exclude people or
treat them differently because of race, color, national origin, age. disability or sex.
HPHC:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign
language interpreters and written information in other formats (large print, audio, otter formats)
• Provides free language services to people whose prinary language is not English, such as qualified interpreters.
If you need these services, contact our Civil Rights Compliance Officer.
If you believe that HPHC has failed to provide these services a discriminated in another way on the basis of race, color.
national origin, age, disability or sex, you can file a grievance with: Civil Rights Compliance Officer, 93 Worcester St,
Wellesley, MA 02481, (866) 750.2074, TTY service: 711, Fax: (617) 509.3085, Email: civil_rights@harvardpilgrim.org. You
can file a grievance h person or by mail, fax or email. If you need help filing a grievance, the Civil Rights Compliance Officer
is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rghts Complaint Portal, available at
httpsiloaportal.hhs.gov/oa/portalAobby.jsf, or by mail or phone at
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH 8uildng
Washington, D.C. 20201
(800) 368-1019, (800) 537-7697 (TTY)
Complaint forms are available at httpJ/w wr.hhs.govlocrlofficelfilelindex.hhnl.
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut,
Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
cc6589_memb_sery (11/9)