Harvard Pilgrim Health Care

NH Local Choice HMO Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $2,000.00 Family: $4000 Per Person: $2000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17400 Per Person: $8700

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable 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.
Specialist	CoPay: $50.00 CoInsurance: Not Applicable 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: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Members save money by obtaining a 90-day supply of 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 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 tool 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: Not Applicable CoInsurance: 25.00% Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Emergency room copayments are waived when a member is directly admitted to the hospital.
Urgent Care Facility	CoPay: $35.00 CoInsurance: Not Applicable 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.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 25.00% Covered: Covered Benefit Explanation: 48 Hour Minimum Stay-Vaginal; 96 Hour Minimum Stay-Cesarean.
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: No Charge Covered: Covered Benefit Explanation: Routine Prenatal and Postnatal Care are covered in full.

Vision

Routine Eye Exams for Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Members under the age of 19 are covered for one routine eye exam every year.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Benefit Explanation: Coverage is not provided for pediatric dental care.
Routine Dental Checkups for Adults	Covered: Not Covered