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

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
1.800.542.1499

 

Calendar Year Deductible

$250 per individual up to a maximum of $750 per family.  

In-Network Out-Of-Pocket Maximum

Excludes Prescription Drugs

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

Copays Effective July 1, 2014

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):  $20 per visit
**Tier 2 (good):          $35 per visit
*Tier 3 (standard): $45 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:   $250 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)

$150 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:   $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:

Berkshire

Handbook

Harvard Pilgrim Primary Choice Plan FY14 Benefit Handbook doc format of    HarvardPrimaryChoiceFY14.doc  file size 2MB pdf format of harvardprimarychoicehandbookfy14.pdf file size 1MB

Harvard Pilgrim Primary Choice Plan FY14 Prescription Drug Brochure doc format of    harvardprimarychoicerxfy14.doc  pdf format of harvardprimarychoicerxfy14.pdf

Harvard Pilgrim Primary Choice Plan FY14 Schedule of Benefits doc format of    harvardprimarychoicesobfy14.doc  pdf format of harvardindependencesobfy14.pdf

 


This information provided by the Group Insurance Commission.