The Office of Human Resources

Home / Open Enrollment 2024 / Harvard Pilgrim Health Care

Harvard Pilgrim Health Care

2024 Plan Services Comparison Chart

Covered Services	HMO HDHP/HSA (Best Buy HSA) (Deductible applies 1st for all services)	HMO Value Deductible (Best Buy HMO)	HMO Premium	PPO In-Network Benefit	PPO Out-of-Network (after deductible)
Provider Network	HPHC	HPHC	HPHC	HPHC /United Health Care	none
Out of Pocket Maximum	$2,500 for single $5,000 for family	$2,500 for single $5,000 for family	$2,500 for single $5,000 for family	$2,500 for single $5,000 for family	$2,500 for single $5,000 for family
Annual Deductible	$1600 for single $3200 for family	$500 for Single $1,000 for Family	N/A	N/A	$500 for Single $1,000 for Family
Urgent Care	Covered in full after deductible met	$25 per visit	$25 per visit	$25 per visit	20% co-insurance after deductible
Emergency Room	Covered after deductible	$150 / visit (waived if admitted)	$150 / visit (waived if admitted)	$150 / visit (waived if admitted)	$150 / visit (waived if admitted)
Hospital	Covered after deductible	$500 per admission after deductible	Covered in full	$500 / admission	20% co-insurance
Day Surgery	Covered after deductible	$250 per surgery after deductible	Covered in full	$250 per surgery	20% co-insurance after deductible
Outpatient Care - *Annual Routine Preventative Services*
Preventive services	Covered in full	Covered in full	Covered in full	Covered in full	20% co-insurance after deductible
Routine physical exams (including most preventive screenings), Well-Child Care, Preventive Immunizations, Preventive Pap Smears, Preventive Mammograms & Routine Colonoscopies (Colonoscopies which include any surgical removal will not be considered preventive, and will be subject to the copay, deductible and/or coinsurance).
OBGYN visits	Covered after deductible	$25 per visit	$25 per visit	$25 per visit	20% co-insurance after deductible
Hearing Exam	Covered after deductible	$25 per visit	$25 per visit	$25 per visit	20% co-insurance after deductible
Allergy shots	Covered after deductible	$5 per visit	$5 per visit	$5 per visit	20% co-insurance after deductible
*Outpatient Care Non-Routine Services*
Office Visits	Covered after deductible	$25 per visit	$25 per visit	$25 per visit	20% co-insurance after deductible
Office Visits – Specialist	Covered after deductible	$25 per visit – referral required	$25 per visit – referral required	$25 per visit	20% co-insurance after deductible
Diagnostic Test, Lab work	Covered after deductible	Deductible only	$25 per visit	Covered in full	20% co-insurance after deductible
Eye Exam –HPHC network	Covered after deductible	$25 once every 12 months	$25 once every 12 months	$25 once every 12 months	20% co-insurance after deductible
High Tech Imaging	Covered after deductible	$75 / max 2 payments per year	$75 / max 2 payments	$75 / max 2 payments	20% co-insurance after deductible
Maternity
Prenatal/ Postnatal Care (routine)	Covered after deductible	Covered in full	Covered in full	Covered in full	20% co-insurance after deductible
Office visits	Covered after deductible	$25 per visit	$25 per visit	$25 per visit	20% co-insurance after deductible
Hospital/ Delivery	Covered after deductible	$500 / admission after deductible	Covered in full	$500 / admission	20% co-insurance after deductible
Mental & Behavioral Health or Substance Abuse Services
Inpatient	Covered after deductible	$500 / admission after deductible	Covered in full	$500 / admission	20% co-insurance after deductible.
Outpatient	Covered after deductible	$25 / visit	$25 / visit	$25 / visit	20% co-insurance after deductible
Prescriptions Drugs
Prescription (up to a 30-day supply)	After deductible is met $15 , $30, $150	$15 – Tier I $30 – Tier II $50 – Tier III	$15 – Tier I $30 – Tier II $50 – Tier III	$15 – Tier I $30 – Tier II $50 – Tier III	Reimbursed at in network level
Mail Order Rx Drugs (up to a 90-day supply)	After deductible is met $30 , $60, $150	$30 – Tier I $60 – Tier II $150 – Tier III	$30 – Tier I $60 – Tier II $150 – Tier III	$30 – Tier I $60 – Tier II $150 – Tier III	Reimbursed at in network level
Specialty Rx Drugs (up to a 30-day supply)	After deductible is met $15 , $30, $150	$15 – Tier I $30 – Tier II $50 – Tier III	$15 – Tier I $30 – Tier II $50 – Tier III	$15 – Tier I $30 – Tier II $50 – Tier III	Not Covered
Prescriptions are administered by OptumRx. More information available at www. Optumrx.com or 855-546-3439
Specialized Services
Habilitative/Rehabilitative Services
Short-term physical therapy Occ therapy	Covered after deductible 60 visits per type of therapy	$25 per visit – 60 visits per type of therapy	$25 per visit – 60 visits per type of therapy	$25 per visit –60 visits per type of therapy	20% co-insurance –60 visits per type of therapy
Speech therapy	Covered after deductible	$25 per visit – unlimited visits	$25 per visit – unlimited visits	$25 per visit – unlimited visits	20% co-insurance – unlimited visits
Rehab Hospital Care (Prior auth required)	Covered after deductible -60 days per year	$500 per admission after deductible -60 days per year	Covered in full –60 days per year	$500 per admission -60 days per year	$500 per admission after deductible -60 days per year
Skilled Nursing Care (Prior auth required	Covered after deductible -100 days per year	$500 per admission after deductible -100 days per year	Covered in full-100 days per year	$500 per admission -100 days per year	$500 per admission after deductible -100 days per year
Durable Medical Equipment (DME)/ Prosthetics	20% co-insurance after deductible.	20% co-insurance	20% co-insurance	20% co-insurance	20% co-insurance after deductible
Hearing Aids	Deductible, then no charge. Limited to $2,000 per hearing aid every 36 months	First $2,000 covered per ear every 36 months, 20% DME co-insurance after limit has been reached	First $2,000 covered per ear every 36 months, 20% DME co-insurance after limit has been reached	First $2,000 covered per ear every 36 months, 20% DME co-insurance after limit has been reached	20% co-insurance after deductible
Chiropractic Acupuncture Services	Covered after deductible	$25 per visit -unlimited visits	$25 per visit - unlimited visits	$25 per visit -unlimited visits	20% co-insurance -unlimited visits