Plan Overview
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, 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.
1.800.542.1499
Calendar Year Deductible
$250 per individual up to a maximum of $750 per family.
Copays Effective July 1, 2013
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, 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
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
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
Handbooks:
Harvard Pilgrim Primary Choice Plan FY13 Benefit Handbook 
file size 1MB
Harvard Pilgrim Primary Choice Plan FY13 Benefit Handbook 
file size 1MB
Harvard Pilgrim Primary Choice Plan FY12 Schedule of Benefits
Harvard Pilgrim Primary Choice Plan FY12 Schedule of Benefits
Harvard Pilgrim Primary Choice Plan FY12 Prescription Drug Coverage
This information provided by the Group Insurance Commission.
