HMO HSA 3400 - Flex Plan Details for 2021- HealthPocket

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Applicant Info
Applicant
Date of birth
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Gender
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female
Income
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Zip Code	02128 (edit)
Applicant	1/21/1986 Male (edit)

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

+ See All Coverage Details

Premium	Plan Name	Deductible
from $342	Focus HMO HSA 3400	$3,400.00	Select
from $354	Premier Bronze Saver 3600	$3,600.00	Select
from $378	Advantage HMO Saver 3600	$3,600.00	Select
from $393	HMO 3500 - Flex	$3,500.00	Select
from $400	HMO HSA 3400 - Flex	$3,400.00	Select

Last Name

Location/Distance

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Jackie, Fantes

Loretta, Chou

Pengwynne, Blevins

Charles, Williams

Lisa, Scarfo

Jonathan, Hatoun

Kristen, Pompey

East Boston Behavioral Health And Medicine Llc

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Madison, Kronheim

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Gina, Campanella

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Nairobi, Oller-laureano

Jacklyn, Giampa

Mary, Gallagher

Meghan, Riedy

Victoria, Shopland

Jessica, Maclean

Nairoby, Nunez

Julia, Bird

Alison, Carr

Adrianna, D'aurora

Jackie Fantes, MD

Phone Number
(617) 569-5800
Office Locations
10 Gove St
East Boston, MA 02128

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Date of birth
//
Gender
male
female
Income
$

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HMO HSA 3400 - Flex

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

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