Plan Overview

Effective July 1, 2015, the Harvard Pilgrim Independence Plan, administered by Harvard Pilgrim Health Care, will become a POS plan that that provides coverage for treatment by a network of doctors, hospitals and other health care providers. Members must select a PCP to manage their care and obtain referrals to specialists to receive care at the in-network level of coverage. It also allows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referral, but with higher out-of-pocket costs.

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 or Tier 2 hospitals.  Contact the plan to see which tier your hospital is in.

Plan Contact Information

Contact the plan for additional information on participating providers and benefits.

Harvard Pilgrim Health Care 1.800.542.1499

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 Drug Costs

$5,000 per individual; $10,000 per family

In-Network Copays Effective July 1, 2015

Primary Care Provider Office Visit

 $20 per visit

Preventive Services

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

Retail Clinic

$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

Tier 3:   $1,500 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

Emergency Room
$100 per visit (waived if admitted)

Prescription Drug

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 Independence Plan is available throughout Massachusetts.

The plan is also available in the following other states:

Maine, New Hampshire, Rhode Island

The Harvard Pilgrim Independence Plan is available only in certain parts of the following states; contact the plan to find out if you live in the service area:

Connecticut, New York, Vermont

Handbook

FY16 Harvard Independence Handbook  docx format of FY16 Harvard Independence Handbook
file size 2MB

FY16 Harvard Independence Schedule of Benefits  docx format of FY16 Harvard Independence Schedule of Benefits

FY16 Harvard Independence Prescription Drug Brochure  docx format of FY16 Harvard Independence Prescription Drug Brochure
  


This information provided by the Group Insurance Commission .