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The Harvard Pilgrim Primary Choice Plan, 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
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.
Contact the plan for additional information on participating providers and benefits.
Harvard Pilgrim Health Care
$500 per individual/$1,000 per family.
Prescription Drug Deductible
$100 per individual/$200 per family
$5,000 per individual; $10,000 per family
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
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
$100 per visit (waived if admitted)
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
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
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
M-F 8:45 a.m.-5 p.m.