Zip Code | 02128 |
Applicant | 1/21/1986 Male |
Insurance Type | ACA (Obamacare) |
Plan Name | HMO HSA 3400 - Flex |
Plan ID | hhs-36046MA0750048 |
Plan Year | 2020 |
Insurance Provider | Harvard Pilgrim |
Metal Level | Expanded Bronze |
Plan Type | HMO |
Deductible | $3,400 |
Out-of-Pocket Maximum | $6,850 |
Plan Highlights |
Costs for Medical Care | |
---|---|
Primary Care Visit to Treat an Injury or Illness | $40 Copay after deductible |
Specialist Visit | $65 Copay after deductible |
Laboratory Outpatient and Professional Services | No Charge after deductible |
X-rays and Diagnostic Imaging | $65 Copay after deductible |
Diagnostic Imaging such as MRIs, CT, and PET scans | $500 Copay after deductible |
Deductible - Family | $6800 per group |
Out-of-Pocket Maximum - Family | $13700 per group |
Prescription drug coverage | |
---|---|
Generic Drugs | $5 Copay after deductible |
Preferred Brand Drugs | 50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs | 50.00% Coinsurance after deductible |
Specialty Drugs | 50.00% Coinsurance after deductible |
Access to doctors and hospitals | |
---|---|
Provider directory URL | http://www.providerlookuponline.com/Harvardpilgrim/po7/Search.aspx |
Does this plan have access to a national provider network? | No |
Is a referral required to see a Specialist? | Yes - A Referral is Needed for all Specialist except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers. |
Does this plan cover services outside plan service area? | Not Covered |
Does this plan cover services outside the country? | Not Covered |
Hospital services | |
---|---|
Emergency Room Services | $750 Copay after deductible |
Inpatient Hospital Services (e.g., Hospital Stay) | 20.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services | 20.00% Coinsurance after deductible |
Emergency Transportation or Ambulance Service | $250 Copay after deductible |
Maternity | |
---|---|
Prenatal and Postnatal Care | No Charge |
Delivery and all inpatient services for maternity care | 20.00% Coinsurance after deductible |
Mental Health | |
---|---|
Mental/Behavioral Health Outpatient Services | $40 Copay after deductible |
Mental/Behavioral Health Inpatient Services | 20.00% Coinsurance after deductible |
Substance use disorder outpatient services | $40 Copay after deductible |
Substance use disorder inpatient services | 20.00% Coinsurance after deductible |
Medical Management Programs | |
---|---|
Does this plan offer disease managment programs? | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
Does this plan offer a wellness program? | Included |
Vision Coverage | |
---|---|
Routine Eye Exam for Children | Included |
Eye Glasses for Children | Included |
Routine Eye Exam for Adults | Included |
Child Dental Coverage | |
---|---|
Child Dental Coverage - Routine Dental Care | Included |
Child Dental Coverage - Basic Dental Care | Included |
Child Dental Coverage - Orthodontia | Included |
Child Dental Coverage - Major Dental Care | Included |
Adult Dental Coverage | |
---|---|
Adult Dental Coverage - Routine Dental Care | Not Covered |
Adult Dental Coverage - Basic Dental Care | Not Covered |
Adult Dental Coverage - Orthodontia | Not Covered |
Adult Dental Coverage - Major Dental Care | Not Covered |
Exclusions and Limitations | |
---|---|
More Included Benefits | Other Practitioner Office Visit (Nurse, Physician Assistant) Preventive Care/Screening/Immunization Acupuncture Bariatric Surgery Infertility Treatment Imaging (CT/PET Scans, MRIs) Outpatient Surgery Physician/Surgical Services Urgent Care Centers or Facilities Inpatient Physician and Surgical Services Home Health Care Services Durable Medical Equipment Hospice Services Chiropractic Care Routine Foot Care Diabetes Care Management Abortion for Which Public Funding is Prohibited Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Nutritional Counseling Prosthetic Devices Radiation Reconstructive Surgery Rehabilitative Speech Therapy Transplant Well Baby Visits and Care Bone Marrow Transplants for Treatment of Breast Cancer Cardiac Rehabilitation Clinical Trials Congenital Anomaly, including Cleft Lip/Palate Contraceptive Services Early Intervention Services Hormone Replacement Therapy (HRT) Human Leukocyte Antigen Testing Hypodermic Syringes or Needles Nutrition/Formulas Off Label Prescription Drugs Childbirth Classes Fitness Club Reimbursement Low Protein Foods Minor Dental Care - Child Retail Health Clinics Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Inherited Metabolic Disorders - PKU |
More Limited Benefits | Skilled Nursing Facility Hearing Aids Weight Loss Programs Outpatient Rehabilitation Services Habilitation Services Dental Check-Up for Children Inpatient Rehabilitation Services Rehabilitative Occupational and Rehabilitative Physical Therapy Treatment for Temporomandibular Joint Disorders Wigs |
More Excluded Benefits | Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing |
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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.