X ScheduleofBenefitssites.dreamingcode.com/DCContentNET/Content/NewData/pdf/66_2… · ID:MD0000003282 X ScheduleofBenefits HarvardPilgrimHealthCare,Inc. THEHARVARDPILGRIMBESTBUYTIEREDCOPAYMENTHMO1000

ID: MD0000003282X

Schedule of BenefitsHarvard Pilgrim Health Care, Inc.THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO 1000MASSACHUSETTS

This Schedule of Benefits summarizes your Benefits under The Harvard Pilgrim Best Buy TieredCopayment HMO 1000 (the Plan) and states the Member Cost Sharing amounts that you mustpay for Covered Benefits. However, it is only a summary of your benefits. Please see your BenefitHandbook and Prescription Drug Brochure (if you have the Plan’s outpatient pharmacy coverage)for detailed information on benefits covered by the Plan and the terms and conditions ofcoverage.

Services are covered when Medically Necessary. Subject to the exceptions listed in the section ofthe Benefit Handbook titled, “How The Plan Works” all services must be (1) provided or arrangedby your Primary Care Provider (PCP) and (2) provided by a Plan Provider. These requirements donot apply to care needed in a Medical Emergency.

In a Medical Emergency you should go to the nearest emergency facility or call 911 or otherlocal emergency access number. A Referral from your PCP is not needed. Your emergency roomMember Cost Sharing, including your Deductible if applicable, is listed in the tables below.

We use clinical review criteria to evaluate whether certain services or procedures are MedicallyNecessary for a Member’s care. Members or their practitioners may obtain a copy of our clinicalreview criteria applicable to a service or procedure for which coverage is requested. Clinicalreview criteria may be obtained by calling 1-888-888-4742 ext. 38723.

Your Covered Benefits are administered on a Plan Year basis. Your Plan Year begins on yourEmployer’s Anniversary Date. Please see your Benefit Handbook for more details. If you do notknow your Employer’s Anniversary Date, please contact your Employer’s benefits office or call theMember Services Department at 1-888-333-4742.

DEDUCTIBLE

A Deductible is a specific annual dollar amount that is payable by the Member for CoveredBenefits received each Plan Year before any benefits subject to the Deductible are payable by thePlan. If a family Deductible applies, it is met when any combination of Members in a coveredfamily incur expenses for services to which the Deductible applies.

Not all services under this Plan are subject to the Deductible. Deductible amounts are incurred onthe date of service. Your Plan Deductible amounts are listed below.

Your Plan has both an individual Deductible and a family Deductible. However, please note that aFamily Deductible only applies if you have Family coverage. Unless a family Deductible applies,you are responsible for the individual Deductible for Covered Benefits each Plan Year. If you are aMember with a family Deductible, your Deductible can be satisfied in one of two ways:

a. If a Member of a covered family meets the individual Deductible, then services for thatMember that are subject to that Deductible are covered by the Plan for the remainder ofthe Plan Year.

EFFECTIVE DATE: 01/01/2014

FORM #1565 SCHEDULE OF BENEFITS | 1

THE HARVARD PILGRIM BEST BUY TIERED COPAYMENT HMO 1000 - MASSACHUSETTS

b. If any number of Members in a covered family collectively meet the family Deductible, thenall Members of the covered family receive coverage for services subject to that Deductible forthe remainder of the Plan Year.

Once a Deductible is met, coverage by the Plan is subject to any other Member Cost Sharingthat may apply.

Your Deductible applies to all services covered under the Plan except the following:

• Applied Behavior Analysis

• Blood glucose monitors, insulin pumps and infusion devices

• Early intervention services

• Examinations and consultations performed by physicians and podiatrists, including periodicroutine exams for preventive care

• Family planning consultations and consultations concerning contraception

• Outpatient mental health care services (including the treatment of substance abusedisorders)

• Preventive Care and Preventive Services and Tests, including FDA approved contraceptivedevices

• Routine prenatal and postpartum care in a physician's office

• Routine nursery charges for newborn care

• Spinal Manipulative Therapy (including care by a chiropractor)

• Well child care, including vision and auditory screenings

Please note: (1) treatments and procedures by physicians and podiatrists and (2) psychologicaltesting and neuropsychological assessment are subject to the Deductible.

PRESCRIPTION DRUG DEDUCTIBLEIf your Plan includes outpatient pharmacy coverage, your drug benefit may be subject to aseparate Deductible. Payments made toward the prescription drug Deductible are not countedtoward the Deductible amount(s) listed below. Please refer to your Prescription Drug Brochure forspecific information on your prescription drug Deductible, if any.

DEDUCTIBLE AND OTHER COST SHARINGFor certain services, both a Deductible and either a Copayment or Coinsurance may apply. In suchcases, you must completely satisfy the Deductible before the Plan pays benefits on services subjectto the Deductible. Once you have satisfied the annual Deductible, you are still responsible forany applicable Copayments or Coinsurance.

COINSURANCE

Coinsurance is a percentage of the cost for certain covered services that is payable by the Member.Please see the tables below for the Coinsurance amounts that apply to your Plan.

COPAYMENTS

A Copayment is a dollar amount that is payable by the Member for certain covered services. TheCopayment is due at the time services are rendered or when billed by the provider. Different



Copayments apply depending on the type of service, the specialty of the provider and thelocation of service.

There are two types of outpatient Copayments that apply to your Plan. A lower Copayment,known as “Copayment Level 1,” applies to some outpatient services, including most primarycare, obstetrical care, gynecological care, and mental health care (including the treatmentof substance abuse disorders). Most outpatient specialty care requires payment of a higherCopayment, known as “Copayment Level 2.” The Level 1 and Level 2 Copayments that apply toyour Plan are listed below.

With the exception of certain preventive services, which are never subject to MemberCost Sharing, the following Copayments apply to the outpatient services covered byyour Plan:

COPAYMENT LEVEL 1Copayment Level 1 always applies to the following outpatient services regardless of the provideror location of service:

• Applied Behavior Analysis

• Mental health care (including the treatment of substance abuse disorders)

• Routine eye examinations

In addition to the Level 1 Services listed above, Copayment Level 1 applies to covered outpatientprofessional services, other than services received at a professional office operated by a hospital,from the following types of providers:

• All Primary Care Providers. The term “Primary Care Provider” (PCP) includes physicians,physician assistants and nurse practitioners in the following specialties: Internal Medicine,Family Practice, General Practice and Pediatrics

• Obstetricians and Gynecologists

• Certified Nurse Midwives

• Nurse Practitioners who bill independently

• Chiropractors

• Podiatrists

COPAYMENT LEVEL 2Copayment Level 2 applies to the following outpatient professional services:

• Any covered service or provider that is not listed under Copayment Level 1 or

• Any service provided in a hospital operated doctor’s office, except the specific services listedunder Copayment Level 1 above.

If a provider is categorized as both a Copayment Level 1 provider and a Copayment Level 2provider, Copayment Level 1 applies. For example, if a provider is both a PCP and a cardiologist,you will be responsible for Copayment Level 1.

A Copayment applies to all services except where specifically stated in the tables below.

Please Note: Occasionally the Copayment may exceed the contract rate payable by the Plan for a service. If theCopayment is greater than the contract rate, you are responsible for the full Copayment, and the provider keepsthe entire Copayment.



General Cost Sharing Features: Member Cost Sharing:Tiered Copaymentsj

Copayment Level 1: Your Plan has a $25 Copayment per visitCopayment Level 2: Your Plan has a $40 Copayment per visit

Coinsurance and other CopaymentsjSee Covered Benefits below

Deductiblej– The Deductible applies to all services

except where specifically notedbelow.

$1,000 per Member per Plan Year$2,000 per family per Plan Year

Out-of-Pocket Maximum jIncludes all Member Cost Sharing exceptthe following benefits, which have aseparate Out-of-Pocket Maximum:– Pediatric dental care

$4,500 per Member per Plan Year$9,000 per family per Plan Year

Benefit Member Cost Sharing:

Ambulance Transportj– Emergency ambulance transport Deductible, then no charge

– Non-emergency ambulance transport Deductible, then no charge

Autism Spectrum Disorders TreatmentjApplied Behavior Analysis Copayment Level 1: $25 Copayment per visit

Chemotherapy and Radiation Therapy – Other than Inpatientj– Outpatient hospital or other facility Deductible, then no charge

– Physician office visit Copayment Level 1: $25 Copayment per visitCopayment Level 2: $40 Copayment per visit

Dental ServicesjImportant Notice: Coverage of Dental Care is very limited. Please see your Benefit Handbook forthe details of your coverage.– Emergency Dental CarePlease Note: Services must be receivedwithin 3 days of injury

Your Member Cost Sharing will depend upon the types ofservices provided, as listed in this Schedule of Benefits.For example, for services provided in a dentist’s office, see“Physician and Other Professional Office Visits.” For servicesprovided in a hospital emergency room, see “EmergencyRoom Care.”

– Extraction of teeth impacted in bone Your Member Cost Sharing will depend upon the types ofservices provided, as listed in this Schedule of Benefits.For example, for services provided in a dentist’s office, see“Physician and Other Professional Office Visits.”

If your Plan provides coverage for pediatric dental services, please see your pediatric dentalrider for coverage information.Dialysisj– Dialysis services Deductible, then no charge




Dialysis (Continued)– Installation of home equipment Deductible, then no charge

Durable Medical Equipmentj– Durable Medical Equipment Deductible, then 20% Coinsurance

– Blood Glucose Monitors, InfusionDevices and Insulin Pumps (includingsupplies)

No charge

– Oxygen and Respiratory Equipment No charge

Early Intervention ServicesjNo charge

Emergency Room CarejDeductible, then $150 Copayment per visitThis Copayment is waived if admitted to the hospital directlyfrom the emergency room.

Hearing Aids (for Members up to the age of 22)j– Limited to $2,000 per hearing aid

every 36 months, for each hearingimpaired ear

No charge

Home Health CarejDeductible, then no chargeNo benefit limits apply to physical therapy, occupationaltherapy or speech therapy received as part of authorizedhome health care.

Hospice – Outpatient ServicesjDeductible, then no charge

Hospital – Inpatient Servicesj– Acute Hospital Care Deductible, then no charge– Inpatient Maternity Care Deductible, then no charge– Inpatient Routine Nursery Care,

including prophylactic medication toprevent gonorrhea

No charge

– Inpatient Rehabilitation – Limited to60 days per Plan Year

Deductible, then no charge

– Skilled Nursing Facility – Limited to100 days per Plan Year


Infertility Services and Treatments (see the Benefit Handbook for details)jYour Member Cost Sharing will depend upon the types ofservices provided, as listed in this Schedule of Benefits. Forexample, for services provided by a physician, see “Physicianand Other Professional Office Visits.”

Laboratory and Radiology ServicesjLaboratory and x-rays Deductible, then no charge




Laboratory and Radiology Services (Continued)Advanced radiology– CT scans– PET scans– MRI– MRA– Nuclear medicine services

Deductible, then $150 Copayment per procedurePlease note: No Member Cost Sharing applies tocertain preventive care services. For a list of coveredpreventive services, please see the Preventive ServicesNotice at: https://www.harvardpilgrim.org/pls/portal/docs/page/members/for_members/preventive_care_CC4297.pdf

Low Protein FoodsjDeductible, then 20% Coinsurance

Maternity Care - OutpatientjChildbirth classes– Coverage for 1 initial childbirth courseor 1 refresher course per pregnancy(see the Benefit Handbook for details)

No charge

Routine outpatient prenatal and postpartumcare

No charge

Please Note: Routine prenatal and postpartum care is usually received and billed from the same Provideras a single or bundled service. Different Member Cost Sharing may apply to any specialized or non-routineservice that is billed separately from your routine outpatient prenatal and postpartum care. For example,for services provided by another physician or specialist, see “Physician and Other Professional Office Visits”for your applicable Member Cost Sharing. Please see your Benefit Handbook for more informationon maternity care.Medical Formulas j


Mental Health Care (Including the Treatment of Substance Abuse Disorders)jInpatient Mental Health Care Services Deductible, then no chargeIntermediate Mental Health Care Services– Acute residential treatment (includingdetoxification), crisis stabilization andin-home family stabilization

– Intensive outpatient programs, partialhospitalization and day treatmentprograms


Outpatient Mental Health Care Services Group therapy – $10 Copayment per visitIndividual therapy – Copayment Level 1: $25 Copayment pervisit

– Detoxification Copayment Level 1: $25 Copayment per visit– Medication management Copayment Level 1: $25 Copayment per visit– Psychological testing and

neuropsychological assessmentDeductible, then no charge

Ostomy SuppliesjDeductible, then 20% Coinsurance

Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwiselisted in this Schedule of Benefits.)j– Routine examinations for preventive

care, including immunizationsNo charge




Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwiselisted in this Schedule of Benefits.) (Continued)– Consultations, evaluations and sickness

and injury careCopayment Level 1: $25 Copayment per visitCopayment Level 2: $40 Copayment per visit

Treatments and procedures, including but notlimited to:– Administration of injections– Allergy treatments– Casting, suturing and the applicationof dressings

– Genetic counseling– Non-routine foot care– Pregnancy testing– Surgical procedure


– Administration of allergy injections Deductible, then no charge

Preventive Services and Tests jPreventive care services, including allFDA approved contraceptive devices.Under the federal health care reformlaw, many preventive services and testsare covered with no Member CostSharing.For a list of covered preventiveservices, please see the PreventiveServices Notice on our website at:https://www.harvardpilgrim.org/pls/portal/docs/page/members/for_members/preventive_care_CC4297.pdfYou may also get a copy of thePreventive Services Notice by callingthe Member Services Departmentat 1–888–333–4742.

No charge

Under federal law the list of preventive services and tests covered above may change periodically basedon the recommendations of the following agencies:a. Grade “A” and “B” recommendations of the United States Preventive Services Task Force;b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers forDisease Control and Prevention; andc. With respect to services for women, infants, children and adolescents, the Health Resources andServices Administration.Information on the recommendations of these agencies may be foundon the web site of the US Department of Health and Human Services at:http://www.healthcare.gov/center/regulations/prevention/recommendations.html.Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordancewith changes in the recommendations of the agencies listed above. You can find a list of the currentrecommendations for preventive care on Harvard Pilgrim’s web site at www.harvardpilgrim.org.


http://www.healthcare.gov/center/regulations/prevention/recommendations.html

http://www.harvardpilgrim.org



Preventive Services and Tests (Continued)Additional Preventive Services and Tests– All lab handling and venipuncturecharge

– Alpha-Fetoprotein (AFP)– Fetal ultrasound– Group B Streptococcus (GBS)– Hepatitis C testing– Lead level testing– Prostate-specific antigen (PSA)

screening– Routine hemoglobin tests– Routine urinalysis

No charge

Prosthetic DevicesjDeductible, then 20% Coinsurance

Rehabilitation and Habilitation Services - Outpatientj– Cardiac Rehabilitation Deductible, then no charge

– Pulmonary rehabilitation therapy Deductible, then no charge

– Speech-Language and Hearing Services Deductible, then no charge

– Physical and occupational therapiescombined up to 60 visits per Plan Year

Please Note: Outpatient physical andoccupational therapy is covered to theextent Medically Necessary for: (1)children under the age of three and(2) the treatment of Autism SpectrumDisorders.


Scopic Procedures Outpatient Diagnostic and Therapeutic j– Colonoscopy, endoscopy and

sigmoidoscopyYour Member Cost Sharing will depend upon where theservice is provided as listed in this Schedule of Benefits. Forexample, for a service provided in an outpatient surgicalcenter, see "Surgery– Outpatient." For services provided in aphysician’s office, see "Physician and Other Professional OfficeVisits." For inpatient hospital care, see "Hospital – InpatientServices."Please note: No Member Cost Sharing applies tocertain preventive care services. For a list of coveredpreventive services, please see the Preventive ServicesNotice at: https://www.harvardpilgrim.org/pls/portal/docs/page/members/for_members/preventive_care_CC4297.pdf

Spinal Manipulative Therapy (including care by a chiropractor)j– Limited to 12 visits per Plan Year Copayment Level 1: $25 Copayment per visit

Surgery - OutpatientjDeductible, then no charge




Vision Servicesj– Routine eye examinations limited to 1

exam per Plan YearCopayment Level 1: $25 Copayment per visit

– Vision hardware for special conditions Deductible, then no charge

Voluntary SterilizationjYour Member Cost Sharing will depend upon where theservice is provided as listed in this Schedule of Benefits. Forexample, for a service provided in an outpatient surgicalcenter, see “Surgery– Outpatient.” For services provided in aphysician’s office, see “Physician and Other Professional OfficeVisits.” For inpatient hospital care, see “Hospital – InpatientServices.”Please note: No Member Cost Sharing applies tocertain preventive care services. For a list of coveredpreventive services, please see the Preventive ServicesNotice at: https://www.harvardpilgrim.org/pls/portal/docs/page/members/for_members/preventive_care_CC4297.pdf.

Voluntary Termination of PregnancyjYour Member Cost Sharing will depend upon where theservice is provided as listed in this Schedule of Benefits. Forexample, for a service provided in an outpatient surgicalcenter, see “Surgery– Outpatient.” For services provided in aphysician’s office, see “Physician and Other Professional OfficeVisits.” For inpatient hospital care, see “Hospital – InpatientServices.”

Wellness BenefitsjFitness club reimbursement– Coverage is provided for one monthof membership in a qualified healthclub or fitness center with a minimumof $150 per individual or familymembership per Plan Year (see theBenefit Handbook for details)

No charge

Weight loss programs– Coverage provided for 3 months ofmembership at Weight Watchers perPlan Year (see the Benefit Handbookfor details)

No charge

Wigs and Scalp Hair Prostheses as required by lawj– Limited to 1 synthetic monofilament

wig per Plan Year (see the BenefitHandbook for details)

Deductible, then 20% Coinsurance


Harvard Pilgrim Health Care, Inc.MASSACHUSETTS HMOGeneral List of Exclusions

The following list identifies services that are generally excluded from Harvard Pilgrim HMO Plans.Additional services may be excluded related to access or product design. For a complete list of exclusionsplease refer to the specific plan's Benefit Handbook.

Exclusion Description

Alternative Treatments1. Acupuncture services, except when specifically listed as a Covered Benefit.

2. Acupuncture services that are outside the scope of standard acupuncturetreatment, except when specifically listed as a Covered Benefit, includingservices for preventive, maintenance, or wellness care, thermography, hairanalysis, heavy metal screening or mineral studies, massage or soft-tissuetechniques, diagnostic services, x-rays or services related to menstrualcramps.

3. Alternative, holistic or naturopathic services and all procedures,laboratories and nutritional supplements associated with such treatments.

4. Aromatherapy, treatment with crystals and alternative medicine.

5. Health resorts, spas, recreational programs, camps, wilderness programs(therapeutic outdoor programs), outdoor skills programs, relaxation orlifestyle programs, including any services provided in conjunction with, oras part of such types of programs.

6. Massage therapy.

7. Myotherapy.Dental Services

1. Dental Care, except the specific dental services listed as Covered Benefits inthe Plan’s Benefit Handbook and Schedule of Benefits.

2. All services of a dentist for Temporomandibular Joint Dysfunction (TMD).

3. Extraction of teeth, except when specifically listed as a Covered Benefit.

4. Preventive dental care for children, except when specifically listed as aCovered Benefit.

5. Dentures.Durable Medical Equipment and Prosthetic Devices

1. Any devices or special equipment needed for sports or occupationalpurposes.

2. Any home adaptations, including, but not limited to home improvementsand home adaptation equipment.

3. Myoelectric and bionic arms and leg, except when specifically listed as aCovered Benefit.

4. Non-durable medical equipment, unless used as part of the treatment at amedical facility or as part of approved home health care services.

5. Repair or replacement of durable medical equipment or prosthetic devicesas a result of loss, negligence, willful damage, or theft.

EXCLUSIONS DOCUMENT | 1


Experimental, Unproven or Investigational Services1. Any products or services, including, but not limited to, drugs, devices,

treatments, procedures, and diagnostic tests that are Experimental,Unproven, or Investigational.

Foot Care1. Foot orthotics, except for the treatment of severe diabetic foot disease or

when specifically listed as a Covered Benefit.

2. Routine foot care. Examples include nail trimming, cutting or debridingand the cutting or removal of corns and calluses. This exclusion does notapply to preventive foot care for Members with diabetes.

Maternity Services1. Delivery outside the Service Area after the 37th week of pregnancy, or

after you have been told that you are at risk for early delivery.

2. Planned home births.

3. Routine pre-natal and post-partum care when you are traveling outsidethe Service Area.

Mental Health Care1. Biofeedback.

2. Educational services or testing, except services covered under thebenefit for Early Intervention Services. No benefits are provided: (1) foreducational services intended to enhance educational achievement; (2) toresolve problems of school performance; or (3) to treat learning disabilities.

3. Methadone maintenance.

4. Sensory integrative praxis tests.

5. Services for any condition with only a “V Code” designation in theDiagnostic and Statistical Manual of Mental Disorders, which means thatthe condition is not attributable to a mental disorder.

6. Mental health care that is (1) provided to Members who are confined orcommitted to a jail, house of correction, prison, or custodial facility ofthe Department of Youth Services; or (2) provided by the Department ofMental Health.

7. Services or supplies for the diagnosis or treatment of mental healthand substance abuse disorders that, in the reasonable judgment of theBehavioral Health Access Center, are any of the following:• Not consistent with prevailing national standards of clinical practice for

the treatment of such conditions.• Not consistent with prevailing professional research demonstrating

that the services or supplies will have a measurable and beneficialhealth outcome.

• Typically do not result in outcomes demonstrably better than otheravailable treatment alternatives that are less intensive or more costeffective.

8. Services related to autism spectrum disorders provided under anindividualized education program (IEP), including any services providedunder an IEP that are delivered by school personnel or any servicesprovided under an IEP purchased from a contractor or vendor.



Physical Appearance1. Cosmetic Services, including drugs, devices, treatments and procedures,

except for (1) Cosmetic Services that are incidental to the correction of aPhysical Functional Impairment, (2) restorative surgery to repair or restoreappearance damaged by an accidental injury, and (3) post-mastectomycare.

2. Hair removal or restoration, including, but not limited to, electrolysis, lasertreatment, transplantation or drug therapy.

3. Liposuction or removal of fat deposits considered undesirable.

4. Scar or tattoo removal or revision procedures (such as salabrasion,chemosurgery and other such skin abrasion procedures).

5. Skin abrasion procedures performed as a treatment for acne.

6. Treatment for skin wrinkles or any treatment to improve the appearanceof the skin.

7. Treatment for spider veins.Procedures and Treatments

1. Care by a chiropractor outside the scope of standard chiropractic practice,including but not limited to, surgery, prescription or dispensing of drugsor medications, internal examinations, obstetrical practice, or treatmentof infections and diagnostic testing for chiropractic care other than aninitial X-ray.

2. Spinal manipulative therapy (including care by a chiropractor), exceptwhen specifically listed as a Covered Benefit.

3. Commercial diet plans, weight loss programs and any services in connectionwith such plans or programs.

4. Gender reassignment surgery and all related drugs and procedures.

5. If a service is listed as requiring that it be provided at a Center ofExcellence, no coverage will be provided if that service is received from aProvider that has not been designated as a Center of Excellence.

6. Nutritional or cosmetic therapy using vitamins, minerals or elements, andother nutrition-based therapy. Examples include supplements, electrolytes,and foods of any kind (including high protein foods and low carbohydratefoods).

7. Physical examinations and testing for insurance, licensing or employment.

8. Services for Members who are donors for non-members, except asdescribed under Human Organ Transplant Services.

9. Testing for central auditory processing.

10. Group diabetes training, educational programs or camps.



Providers1. Charges for services which were provided after the date on which your

membership ends.

2. Charges for any products or services, including, but not limited to,professional fees, medical equipment, drugs, and hospital or other facilitycharges, that are related to any care that is not a Covered Benefit.

3. Charges for missed appointments.

4. Concierge service fees. (See the Plan’s Benefit Handbook for moreinformation.)

5. Follow-up care after an emergency room visit, unless provided or arrangedby your PCP.

6. Inpatient charges after your hospital discharge.

7. Provider's charge to file a claim or to transcribe or copy your medicalrecords.

8. Services or supplies provided by: (1) anyone related to you by blood,marriage or adoption, or (2) anyone who ordinarily lives with you.

Reproduction1. Any form of Surrogacy or services for a gestational carrier.

2. Infertility drugs if a member is not in a Plan authorized cycle of infertilitytreatment.

3. Infertility drugs, if infertility services are not a Covered Benefit.

4. Infertility drugs that must be purchased at an outpatient pharmacy, unlessyour Plan includes outpatient pharmacy coverage.

5. Infertility treatment for Members who are not medically infertile.

6. Infertility treatment and birth control drugs, implants and devices.

7. Reversal of voluntary sterilization (including any services for infertilityrelated to voluntary sterilization or its reversal).

8. Sperm collection, freezing and storage except as described in the Plan’sBenefit Handbook.

9. Sperm identification when not Medically Necessary (e.g., genderidentification).

10. The following fees: wait list fees, non-medical costs, shipping and handlingcharges etc.

11. Voluntary sterilization, including tubal ligation and vasectomy, exceptwhen specifically listed as a Covered Benefit.

12. Voluntary termination of pregnancy, unless the life of the mother is indanger or unless specifically listed as a Covered Benefit.

Services Provided Under Another Plan1. Costs for any services for which you are entitled to treatment at

government expense, including military service connected disabilities.

2. Costs for services for which payment is required to be made by a Workers'Compensation plan or an Employer under state or federal law.



Types of Care1. Custodial Care.

2. Rest or domiciliary care

3. All institutional charges over the semi-private room rate, except when aprivate room is Medically Necessary.

4. Home health care services that extend beyond care on a short-termintermittent basis.

5. Pain management programs or clinics.

6. Physical conditioning programs such as athletic training, body-building,exercise, fitness, flexibility, and diversion or general motivation.

7. Private duty nursing.

8. Sports medicine clinics.

9. Vocational rehabilitation, or vocational evaluations on job adaptability, jobplacement, or therapy to restore function for a specific occupation.

Vision and Hearing1. Eyeglasses, contact lenses and fittings, except as listed in the Plan’s Benefit

Handbook.

2. Hearing aids for self-insured groups, except when specifically listed as aCovered Benefit.

3. Refractive eye surgery, including, but not limited to, lasik surgery,orthokeratology and lens implantation for the correction of myopia,hyperopia and astigmatism.

4. Routine eye examinations except when specifically listed as a CoveredBenefit.

All Other Exclusions1. Any service or supply furnished in connection with a non-Covered Benefit.

2. Beauty or barber service.

3. Any drug or other product obtained at an outpatient pharmacy, exceptfor pharmacy supplies covered under the benefit for diabetes services andhypodermic syringes and needles, as required by law, unless your Planincludes outpatient pharmacy coverage.

4. Food or nutritional supplements, including, but not limited to,FDA-approved medical foods obtained by prescription, except as requiredby law.

5. Guest services.

6. Services for non-Members.

7. Services for which no charge would be made in the absence of insurance.

8. Services for which no coverage is provided in the Plan’s Benefit Handbook,Schedule of Benefits or Prescription Drug Brochure.

9. Services that are not Medically Necessary.

10. Services your PCP or a Plan Provider has not provided, arranged orapproved except as described in the Plan’s Benefit Handbook.


DATE: 01/01/2014

Pediatric Dental Rider - HMOHarvard Pilgrim Health Care, Inc.(for children under the age of 19)MASSACHUSETTS

The pediatric dental rider identifies the covered dental services as described below for dependents underthe age of 19 enrolled in the Harvard Pilgrim Health Care HMO plan (the Plan). Benefits under this Riderterminate on the date the Dependent reaches the age of 19.

Because this Rider is part of your Evidence of Coverage and is a legal document, we want to give youinformation about the document that will help you understand it. Certain capitalized words have specialmeanings. We have defined these words in either the Benefit Handbook in Section II: Glossary or in thisRider in Section 5: Defined Terms for Pediatric Dental Services.

When we use the words "we," "us," and "our" in this document, we are referring to Harvard PilgrimHealth Care. When we use the words "you" and "your" we are referring to people who are Dependents, asthe term is defined in the Benefit Handbook in Section II: Glossary.

SECTION 1: ACCESSING PEDIATRIC DENTAL SERVICES

Network Benefits

These Covered Benefits apply when you choose to obtain Covered Dental Services from a Plan DentalProvider. You generally are required to pay less to the provider than you would pay for services from aNon-Plan Dental Provider. Network Benefits are determined based on the contracted fee for each CoveredDental Service. In no event, will you be required to pay a Plan Dental Provider an amount for a CoveredDental Service in excess of the contracted fee.

In order for Covered Dental Services to be paid as Network Benefits, you must obtain all Covered DentalServices directly from or through a Plan Dental Provider.

You must always verify the participation status of a Plan Dental Provider prior to seeking services.From time to time, the participation status of a provider may change. You can verify the participationstatus by calling us and/or the provider. If necessary, we can provide assistance in referring you to anPlan Dental Provider.

We will make available to you a Directory of Network Dental Providers. You can also call CustomerService at 1–800–460–0315 to determine which providers participate in the Network. The telephonenumber for Customer Service is on your ID card.

Non-Plan Dental Providers

If you are unable to find a Plan Dental Provider to render your care, you can obtain Covered DentalServices from a Non–Plan Dental Provider. Non–Plan Dental Providers are reimbursed based at the Usualand Customary fee for similarly situated Plan Dental Providers for each Covered Dental Service. Theactual charge made by a Non-Plan Dental Provider for a Covered Dental Service may exceed the Usualand Customary fee. As a result, you may be required to pay a Non–Plan Dental Provider an amountfor a Covered Dental Service in excess of the Usual and Customary fee. In addition, when you obtain

FORM #1622 DENTAL COVERAGE | 1

PEDIATRIC DENTAL RIDER - HMO - MASSACHUSETTS

Covered Dental Services from Non-Plan Dental Providers, you must file a claim with us to be reimbursedfor Eligible Dental Expenses.

Covered Dental Services

You are eligible for Covered Dental Services listed in this Rider if such Dental Services are Necessary andare provided by or under the direction of a Dental Provider.

Covered Benefits are available only for Necessary Dental Services. The fact that a Dental Provider hasperformed or prescribed a procedure or treatment, or the fact that it may be the only available treatment,for a dental disease does not mean that the procedure or treatment is a Covered Dental Service underthis Rider.

Pre-Treatment Estimate

If the charge for a Dental Service is expected to exceed $300 or if a dental exam reveals the need for fixedbridgework, you may notify us of such treatment before treatment begins and receive a pre-treatmentestimate. If you desire a pre-treatment estimate, you or your Dental Provider should send a notice to us,via claim form, within 20 calendar days of the exam. If requested, the Dental Provider must provideus with dental x-rays, study models or other information necessary to evaluate the treatment plan forpurposes of benefit determination.

We will determine if the proposed treatment is a Covered Dental Service and will estimate the amountof payment. The estimate of Covered Benefits payable will be sent to the Dental Provider and will besubject to all terms, conditions and provisions of the Policy. Clinical situations that can be effectivelytreated by a less costly, clinically acceptable alternative procedure will be assigned a benefit based on theless costly procedure.

A pre-treatment estimate of Covered Benefits is not an agreement to pay for expenses. This procedure letsyou know in advance approximately what portion of the expenses will be considered for payment.

Pre-Authorization

Pre-authorization is required for all Orthodontic Services. Speak to your Dental Provider about obtaininga pre-authorization before Orthodontic Services are rendered. You or your Dental Provider can requestPre-Authorization for these services by contacting us at 1–800–460–0315. If you do not obtain apre-authorization, we have a right to deny your claim for failure to comply with this requirement.

If a treatment plan is not submitted, you will be responsible for payment of any dental treatment notapproved by us. Clinical situations that can be effectively treated by a less costly, clinically acceptablealternative procedure will be assigned a Benefit based on the less costly procedure.

SECTION 2: BENEFITS FOR PEDIATRIC DENTAL SERVICES

Covered Benefits are provided for the Dental Services stated in this Section when such services are:

A. Necessary.

B. Provided by or under the direction of a Dental Provider.

C. The least costly clinically appropriate service. Clinical situations that can be effectively treated by a lesscostly, clinically appropriate alternative procedure will be covered based on the least costly procedure.

D. Not excluded as described in Section 3: Pediatric Dental Services exclusions of this Rider.



Benefits

Dental Services Deductibles are calculated on a Plan Year basis.

General Cost Sharing Features Member Cost SharingDental Services Deductible

NoneDental Services Out-of-Pocket Maximum

$1,350 per member

$2,700 per family



TYPE I SERVICES: PREVENTIVE & DIAGNOSTIC BASIC COVERED SERVICES

Benefit Description and Limitations Your Cost SharingDiagnostic ServicesIntraoral Bitewing Radiographs (Bitewing X-ray)

– Limited to 1 set every 6 months

50% Coinsurance

Panorex Radiographs (Full Jaw X-ray) or Complete SeriesRadiographs (Full Set of X-rays)

– Limited to 1 time per 36 months.

50% Coinsurance

Periodic Oral Evaluation (Check up Exam)

– Limited to 2 times per 12 months. Covered as a separateBenefit only if no other service was done during the visitother than X-rays.

50% Coinsurance

Preventive ServicesDental Prophylaxis (Cleanings)

– Limited to 2 times per 12 months.

50% Coinsurance

Fluoride Treatments

– Limited to 2 treatments per 12 months.

50% Coinsurance

Sealants (Protective Coating)

– Limited to one sealant per primary or permanent first andsecond noncarious molars and bicuspids every consecutive36 months.

50% Coinsurance



TYPE II SERVICES: MINOR RESTORATIVE COVERED SERVICES

Benefit Description and Limitations Your Cost SharingMinor Restorative Services, Endodontics, Periodontics, and Oral SurgeryAmalgam Restorations (Silver Fillings)

– Limited to one restoration per member per tooth surface peryear

50% Coinsurance

Composite Resin Restorations (Tooth Colored Fillings)

– Limited to anterior and posterior teeth

50% Coinsurance

Endodontics (Root Canal Therapy), including endodonticretreatment

– covered only when performed on anterior teeth, bicuspidsand first and second molars.

Endodontic Surgery

– covered only when performed on anterior teeth, bicuspidsand first and second molars.

50% Coinsurance

Periodontal Maintenance (Gum Maintenance)

– Limited to 4 treatments per 12 month period followingcompletion of active periodontal therapy

50% Coinsurance

Periodontal Surgery (Gum Surgery)

– Limited 1 quadrant or site per 36 months per surgical area.

50% Coinsurance

Scaling and Root Planing (Deep Cleanings)

– Limited to once per quadrant every 36 months

50% Coinsurance

Simple Extractions (Simple tooth removal) 50% CoinsuranceOral Surgery, including Surgical Extraction 50% CoinsuranceSpace Maintainers

– Covered only when there is a premature loss of teeth that maylead to loss of arch

50% Coinsurance

Adjunctive Services

– General Services (including Emergency Treatment of dentalpain)

– General anesthesia is covered when clinically necessary.

50% Coinsurance

TYPE III SERVICES: MAJOR RESTORATIVE SERVICES

Benefit Description and Limitations Your Cost SharingInlays/Onlays/Crowns (Partial to Full Crowns), including repairsand recementation

50% Coinsurance



Full-coverage composite crowns

– Limited to anterior primary teeth

50% Coinsurance

Occlusal Guards

– Limited to one guard per 12 months

50% Coinsurance

Preventive resin restoration

– Limited to occlusal surfaces

50% Coinsurance

Fixed Prosthetics (Bridges), including repairs

– Limited to 1 per tooth per 60 months

50% Coinsurance

Removable Prosthetics (Full or partial dentures), includingrepairs

– Limited to 1 per tooth per 60 months

50% Coinsurance

Relining and Rebasing Dentures

– Covered if services are performed within 6 months of theinsertion of the denture. Subsequent services are coveredonce every 24 months.

50% Coinsurance

TYPE IV SERVICES: ORTHODONTIA

Benefit Description and Limitations Your Cost SharingOrthodontic Services

Covered Benefits will be paid in equal installments over the course of the entire orthodontic treatmentplan as agreed upon between you and your Dental Provider, starting on the date that the orthodonticbands or appliances are first placed, or on the date a one-step orthodontic procedure is performed.Benefits for comprehensive orthodontic treatment are approved,only in those instances that are related to an identifiablesyndrome such as cleft lip and or palate, Crouzon’s syndrome,Treacher-Collins syndrome, Pierre-Robin syndrome, hemi-facialatrophy, hemi-facial hypertrophy; or other severe craniofacialdeformities which result in a physically handicappingmalocclusion as determined by our dental consultants. Benefitsare not available for comprehensive orthodontic treatment forcrowded dentitions (crooked teeth), excessive spacing betweenteeth, temporomandibular joint (TMJ) conditions and/or havinghorizontal/vertical (overjet/overbite) discrepancies.

Note: All orthodontic treatment must be prior authorized.

50% Coinsurance

SECTION 3: PEDIATRIC DENTAL EXCLUSIONS

Except as may be specifically provided in this Rider under Section 2: Benefits for Covered Dental Services,no benefits are provided under this Rider for the following:1. Any Dental Service or Procedure not listed as a Covered Dental Service in this Rider in Section 2:

Benefits for Covered Dental Services.



2. Dental Services that are not Necessary.3. Hospitalization or other facility charges.4. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are

those procedures that improve physical appearance.)5. Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease,

injury, or congenital anomaly, when the primary purpose is to improve physiological functioning ofthe involved part of the body.

6. Any Dental Procedure not directly associated with dental disease.7. Any Dental Procedure not performed in a dental setting.8. Procedures that are considered to be Experimental, Investigational or Unproven Services. This

includes pharmacological regimens not accepted by the American Dental Association (ADA)Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service,treatment, device or pharmacological regimen is the only available treatment for a particularcondition will not result in Covered Benefits if the procedure is considered to be Experimental,Investigational or Unproven in the treatment of that particular condition.

9. Placement of dental implants, implant-supported abutments and prostheses.10. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and

utilized in the dental office during the patient visit.11. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal

hard tissue.12. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except

excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or softtissue, including excision.

13. Replacement of complete dentures, fixed and removable partial dentures or crowns and implants,implant crowns and prosthesis if damage or breakage was directly related to provider error. Thistype of replacement is the responsibility of the Dental Provider. If replacement is Necessary becauseof patient non-compliance, the patient is liable for the cost of replacement.

14. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper andlower jaw bone surgery (including that related to the temporomandibular joint). Orthognathicsurgery, jaw alignment, and treatment for the temporomandibular joint.

15. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.16. Expenses for Dental Procedures begun prior to the Dependent becoming enrolled for coverage

provided through this Rider to the Policy.17. Dental Services otherwise covered under the Policy, but rendered after the date individual coverage

under the Policy terminates, including Dental Services for dental conditions arising prior to the dateindividual coverage under the Policy terminates.

18. Services rendered by a provider with the same legal residence as a Dependent or who is a member ofa Dependent’s family, including spouse, brother, sister, parent or child.

19. Foreign Services are not covered unless required as a Medical Emergency.20. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or

reconstruction.



21. Attachments to conventional removable prostheses or fixed bridgework. This includessemi-precision or precision attachments associated with partial dentures, crown or bridgeabutments, full or partial overdentures, any internal attachment associated with an implantprosthesis, and any elective endodontic procedure related to a tooth or root involved in theconstruction of a prosthesis of this nature.

22. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion(VDO).

23. Occlusal guards used as safety items or to affect performance primarily in sports-related activities.24. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.25. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as

anesthesia.

SECTION 4: APPEALS AND GRIEVANCES

Appeals

If you are dissatisfied with a decision on our coverage of services, you may appeal. Appeals may also befiled by a Member’s representative or a provider acting on a Member’s behalf and must be received within180 days of the initial denial. Our staff is available to assist you in filing an appeal. If you’d like assistance,please call Customer Service at 1–800–460–0315.

To initiate your appeal, you or your representative should write a letter to us about the coverage youare requesting and why you feel it should be granted. Please be as specific as possible in your appealrequest. We need all the important details in order to make a fair decision. Please send your request tothe following address:

Harvard Pilgrim Health CareAttention: AppealsP.O. Box 30569Salt Lake City, UT 84130–0569

You may also contact us at 1–800–460–0315 to initiate your appeal.

Grievances

If you have a complaint about your care under the Plan or about our service, we want to know aboutit. For all grievances, please call or write to us at:

Harvard Pilgrim Health CareAttention: GrievancesP.O. Box 30569Salt Lake City, UT 84130–0569Telephone: 1–800–460–0315

For additional information on the Appeals and Grievance process, please refer to your Benefit Handbook.

SECTION 5 CLAIMS FOR PEDIATRIC DENTAL SERVICES

When obtaining Dental Services from a Non-Plan Dental Provider, you will be required to pay all billedcharges directly to your Dental Provider. You may then seek reimbursement from us. Information about



claim timelines and responsibilities in the Benefit Handbook in Section V: How to File a Claim apply toCovered Dental Services provided under this Rider, except that when you submit your claim, you mustprovide us with all of the information identified below.

Reimbursement for Dental Services

You are responsible for sending a request for a claim for reimbursement (proof of loss) to our office, on aform provided by or satisfactory to us.

Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof mustinclude all of the following information:• Dependent’s name and address• Dependent’s identification number• The name and address of the provider of the service(s)• A diagnosis from the Dental Provider including a complete dental chart showing extractions, fillings

or other dental services rendered before the charge was incurred for the claim.• Radiographs, lab or hospital reports.• Casts, molds or study models• Itemized bill which includes the CPT or ADA codes or description of each charge.• The date the dental disease began• A statement indicating that you are or you are not enrolled for coverage under any other health

or dental insurance plan or program. If you are enrolled for other coverage you must include thename of the other carrier(s).

If you would like to use a claim form, you can request one be mailed to you by calling Customer Service at1–800–460–0315. This number is also listed on your ID Card. If you do not receive the claim form within15 calendar days of your request, send in the proof of loss with the information stated above.

Please mail your request for reimbursement to the following address:Claims – Harvard Pilgrim Health CareP.O. Box 30567Salt Lake City, UT 84130–0567

Written proof of loss should be given to the Company within 90 days after the date of the loss. If it wasnot reasonably possible to give written proof in the time required, the company will not reduce or denythe claim for this reason. However, proof must be filed as soon as reasonably possible, but no laterthan 1 year after the date of service.

SECTION 6 DEFINED TERMS FOR PEDIATRIC DENTAL SERVICESThe following definitions are in addition to those listed in Section 9: Defined Terms of the Certificate:

Covered Dental Service – a Dental Service or Dental Procedure for which Covered Benefits are providedunder this Rider.

Dental Provider - any dentist or dental practitioner who is duly licensed and qualified under the lawof jurisdiction in which treatment is received to render Dental Services, perform dental surgery oradminister anesthetics for dental surgery.



Dental Service or Dental Procedures - dental care or treatment provided by a Dental Provider to aDependent under the age of 19 while the Policy is in effect, provided such care or treatment is recognizedby us as a generally accepted form of care or treatment according to prevailing standards of dental practice.

Dental Services Deductible - the amount a Dependent under the age of 19 must pay for Covered DentalServices in a Plan Year before we will begin paying for Covered Benefits in that year.

Dental Services Out-of-Pocket Maximum – a limit on the amount of Copayments, Coinsurance andDeductibles that you must pay for Covered Benefits in a Plan Year

Eligible Dental Expenses - Eligible Dental Expenses for Covered Dental Services, incurred while thePolicy is in effect, are determined as stated below:• For Network Benefits, when Covered Dental Services are received from Plan Dental Providers,

Eligible Dental Expenses are our contracted fee(s) for Covered Dental Services with that provider.• For Non-Network Benefits, when Covered Dental Services are received from Non–Plan Dental

Providers, Eligible Dental Expenses are the lesser of the Usual and Customary fees, as defined belowor the billed charges.

Necessary - Dental Services and supplies under this Rider which are determined by us throughcase-by-case assessments of care based on accepted dental practices to be appropriate and are all of thefollowing:• Necessary to meet the basic dental needs of the Dependent under age 19.• Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the

Dental Service.• Consistent in type, frequency and duration of treatment with scientifically based guidelines of

national clinical, research, or health care coverage organizations or governmental agencies that areaccepted by us.

• Consistent with the diagnosis of the condition.• Required for reasons other than the convenience of the Dependent or his or her Dental Provider.• Demonstrated through prevailing peer-reviewed dental literature to be either:

• Safe and effective for treating or diagnosing the condition or sickness for which their useis proposed; or

• Safe with promising efficacy• For treating a life threatening dental disease or condition.• Provided in a clinically controlled research setting.• Using a specific research protocol that meets standards equivalent to those defined by

the National Institutes of Health.(For the purpose of this definition, the term life threatening is used to describe dental diseases orsicknesses or conditions, which are more likely than not to cause death within one year of the dateof the request for treatment.)

The fact that a Dental Provider has performed or prescribed a procedure or treatment or the fact that itmay be the only treatment for a particular dental disease does not mean that it is a Necessary CoveredDental Service as defined in this Rider. The definition of Necessary used in this Rider relates only toBenefits under this Rider and differs from the way in which a Dental Provider engaged in the practice ofdentistry may define necessary.



Usual, Customary and Reasonable Charge - Usual, Customary and Reasonable Charge is the maximumamount that we will pay for services from Dental Providers. The Usual, Customary and ReasonableCharge is calculated using the 80th percentile of provider reimbursement for services in the samegeographic area under the FAIR Health database.


Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts

Coverage Period: 1/1/2014 - 12/31/2014 Coverage for: Individual + Family | Plan Type: HMO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.harvardpilgrim.org or by calling 1-888-333-4742.

Important Questions Answers Why this matters:

What is the overall deductible?

$1,000 per member per Plan Year/ $2,000 per family per Plan Year The deductible applies to benefits cited in the chart starting on Page 3 , for other benefits see your Plan document.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. $4,500 per member per Plan Year/ $9,000 per family per Plan Year Combined with Pharmacy out-of-pocket maximum.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Please see your Schedule of Benefits for out-of-pocket maximum exclusions for your plan.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of preferred providers, see www.harvardpilgrim.org or call 1-888-333-4742.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers.

Questions: Call 1-888-333-4742 or visit us at www.harvardpilgrim.org. If you are not clear about any of the

bolded terms used in this form, see the Glossary. You can view the Glossary at www.harvardpilgrim.org/fhcr

or call 1-888-333-4742 to request a copy.

MD0000003282_A13, RX0000000935_11

, Page 1 of 11

http://www.harvardpilgrim.org/



http://www.harvardpilgrim.org/fhcr

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Page 2 of 11

Important Questions Answers Why this matters:

Do I need a referral to see a specialist?

Yes, some exceptions apply. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 7 . See your policy or plan document for additional information about excluded services.


Page 3 of 11

• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

• Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event Services You May Need Participating Provider Non-Participating

Provider Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

Copayment Level 1: $25 Copayment per visit

Not covered None

Specialist visit Copayment Level 1: $25 Copayment per visit Copayment Level 2: $40 Copayment per visit

Not covered Copayment Level 1 services are generally services of primary care providers.

Copayment Level 2 services are generally specialists.

Other practitioner office visit

Deductible, then no charge Not covered – Chiropractic Care is limited.

Cost sharing may vary for certain practitioners.

Preventive care/screening/immunization

No charge Not covered None

If you have a test Diagnostic test (x-ray, blood work)

Deductible, then no charge Not covered None

Imaging (CT/PET scans, MRIs)

Deductible, then $150 Copayment per procedure

Not covered None


Page 4 of 11

Common Medical Event Services You May Need Participating Provider Non-Participating Provider

Limitations & Exceptions

If you need drugs to treat your illness or condition

More information about

prescription drug coverage is available at www. harvardpilgrim.org.

Most generic drugs Retail Pharmacy Tier 1: $5 Copayment Mail Order Pharmacy Tier 1: $10 Copayment Retail Pharmacy Tier 2: $20 Copayment Mail Order Pharmacy Tier 2: $40 Copayment

Pharmacy Out-of-pocket limit:. $4,500 per member per Plan Year / $9,000 per family per Plan Year Combined with Medical out-of-pocket maximum. – Retail Pharmacy – limited to 30 day supply per refill

– Mail Order Pharmacy – limited to 90 day supply per refill

Preferred brand drugs Retail Pharmacy Tier 3: $30 Copayment Mail Order Pharmacy Tier 3: $60 Copayment

Same as above.

Non-preferred brand drugs Retail Pharmacy Tier 4: $50 Copayment Mail Order Pharmacy Tier 4: $150 Copayment

Some generic drugs are in this tier. Same as above.

Specialty drugs All drugs are covered in Retail Pharmacy and Mail Order Pharmacy Tiers 1 — 4

Must be obtained through a Specialty Pharmacy.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)


Physician/surgeon fees Deductible, then no charge Not covered None

If you need immediate medical attention

Emergency Room Services Deductible, then $150 Copayment per visit

This Copayment is waived if admitted to the hospital directly from the emergency room.

Same As Participating Provider

None

Emergency Medical Transportation

Deductible, then no charge Same As Participating Provider

None

Urgent Care Copayment Level 1: $25 Copayment per visit Copayment Level 2: $40 Copayment per visit

Same As Participating Provider

None


Page 5 of 11



If you have a hospital stay Facility fee (e.g., hospital room)


Physician/surgeon fee Deductible, then no charge Not covered None

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

Group Therapy: $10 Copayment per visit Individual Therapy: $25 Copayment per visit

Not covered None

Mental/Behavioral health inpatient services


Substance use disorder outpatient services

Group Therapy: $10 Copayment per visit Individual Therapy: $25 Copayment per visit

Not covered None

Substance use disorder inpatient services


If you are pregnant Prenatal and postnatal care No charge Not covered None

Delivery and all inpatient services


If you need help recovering or have other special health needs

Home health care Deductible, then no charge Not covered None

Rehabilitation services (Inpatient)

Deductible, then no charge Not covered – Limited to 60 days per Plan Year

Habilitation services (Outpatient)

Deductible, then no charge Not covered – Physical Therapy – limited to 60 visits per Plan Year – Occupational Therapy – limited to 60 visits per Plan Year Physical and Occupational visit limits are combined per Plan Year

Skilled nursing care Deductible, then no charge Not covered – Limited to 100 days per Plan Year


Page 6 of 11



Durable medical equipment

Deductible, then 20% Coinsurance

Not covered – Wigs – limited to 1 synthetic monofilament wig per Plan Year

Hospice services Deductible, then no charge Not covered If inpatient services are required, please see “If you have a hospital stay”.

If your child needs dental or eye care

Eye exam Copayment Level 1: $25 Copayment per visit

Not covered – Limited to 1 exam per Plan Year

You may have other coverage under a Vision Rider.

Glasses Not covered Not covered You may have other coverage under a Vision Rider.

Dental check-up

- Up to the age of 19

50% Coinsurance 50% Coinsurance — Limited to 2 times per 12 months

Cost sharing may vary if employer has selected a different carrier.

You have other coverage under a Dental Rider.


Page 7 of 11

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture

• Long-Term (Custodial) Care

• Most Cosmetic Surgery

• Most Dental Care (Adult)

• Non-emergency care when traveling outside the U.S.

• Private-duty nursing

• Routine foot care

• Weight Loss Programs (Except for certain coverage for groups with less than 50 employees.)

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Bariatric Surgery

• Chiropractic Care

• Hearing Aids

• Infertility Treatments

• Routine eye care (Adult)


Page 8 of 11

Your Rights to Continue Coverage:

Individual health insurance

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

• You commit fraud

• The insurer stops offering services in the State

• You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 1-800-333-4742. You may also contact your state insurance department at: Massachusetts Division of Insurance 1000 Washington Street, Suite 810 Boston, MA 02118–6200 1-617-521-7794.

Your Grievance and Appeals Rights:

Group health coverage

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may

OR also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-333-4742. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact:

HPHC Member Appeals-Member Services Department Harvard Pilgrim Health Care, Inc. 1600 Crown Colony Drive Quincy, MA 02169 Telephone: 1-888-333-4742 Fax: 1-617-509-3085

Department of Labor’s Employee Benefits Security Administration 1-866-444-3272 www.dol.gov/ebsa/healthreform

Health Care for All 30 Winter Street, Suite 1004 Boston, MA 02108 1-800-272-4232 http://www.hcfama.org/helpline

Massachusetts Division of Insurance 1000 Washington Street, Suite 810 Boston, MA 02118–6200 1-617-521-7794

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.dol.gov/ebsa/healthreform

http://www.hcfama.org/helpline


Page 9 of 11

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% ( actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

————— To see examples of how this plan might cover costs for a sample medical situation, see the next page. —————


Page 10 of 11

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Deductibles $140

Co-pays $1,200

Co-insurance $0

Limits or exclusions $80

Total $1,420

About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial

Having a baby (normal delivery)

Managing type 2 diabetes

(routine maintenance of a well-controlled condition)

protection a sample patient might get if they are covered under different plans.

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

■ Amount owed to providers: $7,540 ■ Plan pays: $6,380 ■ Patient pays: $1,160

Sample care costs:

Patient pays:

■ Amount owed to providers: $5,400 ■ Plan pays: $3,980 ■ Patient pays: $1,420

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $1,000

Co-pays $10

Co-insurance $0

Limits or exclusions $150

Total $1,160


Page 11 of 11

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

What does a Coverage Example show?

Can I use Coverage Examples to compare plans?

• Costs don’t include premiums. For each treatment situation, the Coverage ✔ es When you look at the Summary of

• Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and

Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

ended in the same coverage period. ✘

No

Treatments shown are just examples. ✔

Yes

An important cost is the premium you

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in-network providers. If the patient had received care from out-of-network

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help

providers, costs would have been higher. ✘ No

Coverage Examples are not cost you pay out-of-pocket expenses.

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.


All Other Exclusions (Continued)

11. Taxes or governmental assessments on services or supplies.

12. Transportation other than by ambulance.

13. The following products and services:• Air conditioners, air purifiers and filters, dehumidifiers and humidifiers.• Car seats.• Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners.• Electric scooters.• Exercise equipment.• Home modifications including but not limited to elevators, handrails

and ramps.• Hot tubs, jacuzzis, saunas or whirlpools.• Mattresses.• Medical alert systems.• Motorized beds.• Pillows.• Power-operated vehicles.• Stair lifts and stair glides.• Strollers.• Safety equipment.• Vehicle modifications including but not limited to van lifts.• Telephone.• Television.


Documents

X ScheduleofBenefitssites.dreamingcode.com/DCContentNET/Content/NewData/pdf/66_2… · ID:MD0000003282 X ScheduleofBenefits HarvardPilgrimHealthCare,Inc. THEHARVARDPILGRIMBESTBUYTIEREDCOPAYMENTHMO1000