Members must select a Primary Care Provider (PCP) to manage their care, including 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
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.
$250 per individual up to a maximum of $750 per family.
Copays Effective July 1, 2013
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, Obstetrician/Gynecologists, Ophthalmologists, Orthopedists, Otolaryngologists (ENTs), Pulmonologists, and Rheumatologists.
***Tier 1 (excellent): $20 per visit
**Tier 2 (good): $35 per visit
*Tier 3 (standard): $45 per visit
Out-of-State Specialist Office Visit: $35 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: $250 per admission
Tier 2: $500 per admission
Outpatient Surgery (Maximum four copays per person per calendar year)
$150 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: $20
Tier 2: $25 Tier 2: $50
Tier 3: $50 Tier 3: $110
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 FY14 Benefit Handbook file size 2MB file size 1MB
This information provided by the Group Insurance Commission.