Medical Plan High Deductible HMO
HMO HSA $3, 3 00
HMO HSA $5,000
Plan Features
IN-NETWORK $3, 3 00/ $6, 6 00 $5,000/ $10,000
IN-NETWORK
$5,000/ $10,000 $6,000/ $12,000
Deductible (Ind/Family)
Out-of-Pocket Maximum (Ind/Family)
Coinsurance Percentage
You Pay 20%
You Pay 20%
PCP Office Visits Specialist Office Visits Preventive Care
20% After Ded 20% After Ded Covered in Full 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded
20% After Ded 20% After Ded Covered in Full 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded 20% After Ded
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
Emergency Room Services
Prescription Drugs (Rx) Tiers 1 / 2 / 3 /4 / 5 (30 Day Supply)
After Ded: $5 / $20 / $30 / $50 / 30% up to $250 Per RX
After Ded: $5 / $20 / $30 / $50 / 30% up to $250 Per RX
* Deductible waived for Preventive Prescriptions
Harvard Pilgrim Billed Monthly Rates
HMO HSA $3, 3 00
HMO HSA $5,000
$6 06.75
$ 495.99
Employee Only
$1,3 04.51 $1,2 13.52 $1, 881.54
$ 1,066.38
Employee + Spouse Employee + Child(ren)
$ 991.98
$ 1,538.05
Family
Per Pay Period Deductions
HMO HSA $3, 3 00
HMO HSA $5,000
$6 2.27 $15 3.98 $14 1.27 $21 0.85
$11. 15 $4 4.07 $ 39.02
Employee Only
Employee + Spouse Employee + Child(ren)
Family $5 2.32 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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