Benefit Explanation: No cost sharing applies to the first 2 Tier 1 medical office visits per member. Deductible applies after the first 2 Tier 1 medical office visits per member. You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.
Specialist
CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.
Generic Drugs
CoPay: $10.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Certain preventative services are covered at no cost to the member. See a complete list at harvardpilgrim.org Coverage for some generic OTC medications is available at tier 1 Rx cost sharing. You can use the drug lookup took at harvardpilgrim.com/rx to search the formulary for OTC medications you may be taking. Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.
Inpatient Coverage
Hospital Services
CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered
Inpatient Services
CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Emergency room copayments are waived when a member is directly admitted to the hospital.
Urgent Care Facility
CoPay: No Charge after deductible
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Urgent care centers can be both freestanding and hospital-based. Receiving care from freestanding urgent care clinics often has lower member out of pocket cost. To locate freestanding urgent care clinics in our network, search for 'Urgent Care Center' provider type in the online provider directory.
1-817-813-4562, TTY 711
