The Harvard Pilgrim Primary Choice Plan, administered by Harvard Pilgrim Health Care, is an HMO plan that provides coverage through the plan’s network of doctors, hospitals and other providers. Members must select a Primary Care Provider (PCP) to manage their care and obtain referrals to specialists.
Contact the plan to see if your doctors and hospitals are in the network. There are no out-of-network benefits, with the exception of emergency care
Specialist and Hospital Tiering
Harvard Pilgrim Health Care tiers the following Massachusetts specialists based on quality and/or cost efficiency: Allergists/Immunologists, Cardiologists, Dermatologists, Endocrinologists, Gastroenterologists, General Surgeons, Neurologists, Obstetrician/Gynecologists, Ophthalmologists, Orthopedists, Otolaryngologists (ENTs), Pulmonologists, and Rheumatologists. Members pay lower office visit copays when they see Tier 1 or Tier 2 specialists. Contact the plan to see if your provider is in the network and how he/she is rated.
The plan also tiers hospitals based on quality and/or cost; members pay a lower inpatient hospital copay when they use Tier 1 hospitals. Contact the plan to see which tier your hospital is in.
! Your Responsibility
Do your doctors and hospitals participate in Harvard Pilgrim Primary Choice?
Contact the Plan.
Plan Contact Information
Contact the plan for additional information on participating providers and benefits.
Harvard Pilgrim Health Care
Calendar Year Deductible -will transition to fiscal year
$300 per individual up to a maximum of $900 per family.
In-Network Out-Of-Pocket Maximum
Excludes Prescription Drugs
$5,000 per individual; $10,000 per family
Copays Effective July 1, 2015
Primary Care Provider Office Visit
$20 per visit
Most covered at 100% - no copay
Specialist Physician Office Visit
Harvard Pilgrim Health Care tiers the following Massachusetts specialists based on quality and/or cost efficiency: Allergists/Immunologists, Cardiologists, Dermatologists, Endocrinologists, Gastroenterologists, General Surgeons, Neurologists, Obstetricians/Gynecologists, Ophthalmologists, Orthopedists, Otolaryngologists (ENTs), Pulmonologists, and Rheumatologists. Contact the plan to see how your provider is rated.
***Tier 1 (excellent): $30 per visit
**Tier 2 (good): $60 per visit
*Tier 3 (standard): $90 per visit
$20 per visit
Outpatient Mental Health and Substance Abuse Care
$20 per individual visit
Inpatient Hospital Care - Medical (Maximum one copay per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year)
Harvard Pilgrim Health Care tiers its hospitals based on quality and/or cost:
Tier 1: $275 per admission
Tier 2: $500 per admission
Contact the plan to see which tier your hospital is in.
Outpatient Surgery (Maximum four copays per person per calendar year)
$250 per occurrence
High-Tech Imaging (e.g., MRI, PET and CT scans) (Maximum one copay per day)
$100 per scan
$100 per visit (waived if admitted)
Retail up to 30-day supply: Mail Order up to 90-day supply:
Tier 1: $10 Tier 1: $25
Tier 2: $30 Tier 2: $75
Tier 3: $65 Tier 3: $165
Who is Eligible?
Employees, Retirees, Survivors, and their eligible dependents without Medicare are eligible.
Where You Live Determines Which Plan You May Enroll In
The Harvard Pilgrim Primary Choice Plan is available in the following Massachusetts counties:
Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
The Harvard Pilgrim Primary Choice Plan is available only in certain parts of the following Massachusetts county; contact the plan to find out if you live in the service area:
Harvard Pilgrim Primary Choice Plan FY15 Benefits Handbook
This information provided by the Group Insurance Commission .
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