Plan Overview

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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 Changes

Harvard Pilgrim is changing its tiering program to one based on on provider group value instead of individual performance.  This change may affect your copays.  Members will pay lower copays for Tier 1 and Tier 2 specialists and Tier 1 hospitals.  Contact the plan to find out each of your provider’s tier at the office location you visit.    Also 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
1.800.542.1499

 

Fiscal Year Deductible

Medical Deductible
$500 per individual/$1,000 per family. 

Prescription Drug Deductible

$100 per individual/$200 per family

In-Network Out-Of-Pocket Maximum

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

Copays Effective July 1, 2017

Preventive Services

Most covered at 100% - no copay

Primary Care Provider Office Visit

$20 per visit

Specialist Physician Office Visit

Contact the plan to see how your provider is rated.
Tier 1:    $30 per visit
Tier 2:    $60 per visit
Tier 3:    $90 per visit

Retail Clinic and Urgent Care Center

$20 per visit

Outpatient Behavioral Health and Substance Use Disorder 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)

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

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 Primary Choice Plan is available in the following Massachusetts counties:

Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, Worcester

Handbook

FY18 Harvard Primary Choice Handbook  pdf format of FY18 Harvard Primary Choice Handbook
file size 1MB

If you need ADA accommodation to access these materials or are unable to download the attached version of the handbook, contact Harvard Pilgrim:

New members: 1-800-542-1499; email

Current members: 1-888-333-4742; email

 


This information provided by the Group Insurance Commission .