Medical Plan PPO
PPO $2,500
Plan Features
IN-NETWORK $2,500/ $5,000
OUT-OF-NETWORK $5,000/ $10,000
Deductible (Ind/Family)
Prescription Out of Pocket Maximum Medical Out of Pocket Maximum Medical & Prescription Total Out of Pocket Maximum
$1,000/ $2,000
$5,000/ $10,000
$10,000/ $20,000
$6,000/ $12,000
$11,000/ $22,000
Coinsurance Percentage
You Pay 20%
You Pay 40%
PCP Office Visits Specialist Office Visits Preventive Care
40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded 40% After Ded
No cost 1st visit, then $25 C opay $50 Copay Covered in Full
Inpatient Hospital Outpatient Hospital Diagnostic Lab & X-Ray Services Complex Imaging (MRI, CT, PET Scans) Chiropractic Care Physical, Speech and Occupational Therapy Urgent Care Facility
20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded $50 Copay $ 25 Copay
Emergency Room Services
$150 Copay
Prescription Drugs (Rx) Tiers 1 / 2 / 3 /4 / 5 (30 Day Supply)
$5 / $20 / $30 / $50 /30% up to $250 Per RX
Harvard Pilgrim Billed Monthly Rates
Per Pay Period Deductions
$7 27.87
$1 18.17 $ 274.16 $2 53.07 $3 84.21
Employee Only
$1, 564.91 $1, 455.75 $2, 257.13
Employee + Spouse Employee + Child(ren)
Family
Note: For more detailed information on benefits, limitations and exclusions refer to the Summary of Benefits and Summary Plan Description. Please contact Harvard Member Services at the number on the back of your ID Card with questions regarding coverage or claims.
This Guide is for illustrative purposes only and is not a legal contract, contract of employment or guarantee of coverage. Any benefits payable will be subject to the terms and conditions of the insurance policy issued by the insurance company and relevant plan document.
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