PPO 4000 - Flex Plan Details for 2021- HealthPocket

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Zip Code	02128 (edit)
Applicant	6/27/1987 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	PPO 4000 - Flex
Plan ID	hhs-36046MA0790048
Plan Year	2021
Insurance Provider	Harvard Pilgrim
Metal Level	Silver
Plan Type	PPO
Deductible	$4,000
Out-of-Pocket Maximum	$8,000
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$50 Copay after deductible
Specialist Visit	$50 Copay after deductible
Laboratory Outpatient and Professional Services	No Charge
X-rays and Diagnostic Imaging	$75 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	$300 Copay
Deductible - Family	$8000 per group
Out-of-Pocket Maximum - Family	$16000 per group

Prescription drug coverage
Generic Drugs	$5 Copay
Preferred Brand Drugs	$85 Copay
Non-Preferred Brand Drugs	$110 Copay
Specialty Drugs	10.00% Coinsurance

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?	Yes
Is a referral required to see a Specialist?	Not Covered
Does this plan cover services outside plan service area?	Yes - All Covered Benefits except for Emergency Care are covered at the Out of Network Cost Sharing.
Does this plan cover services outside the country?	Yes - All Covered Benefits except for Emergency Care are covered at the Out of Network Cost Sharing.

Hospital services
Emergency Room Services	$350 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$500 Copay per Stay after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Emergency Transportation or Ambulance Service	No Charge after deductible

Maternity
Prenatal and Postnatal Care	No Charge
Delivery and all inpatient services for maternity care	$500 Copay after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	$50 Copay after deductible
Mental/Behavioral Health Inpatient Services	$500 Copay per Stay after deductible
Substance use disorder outpatient services	$50 Copay after deductible
Substance use disorder inpatient services	$500 Copay per Stay 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 Non-Emergency Care When Traveling Outside the U.S. 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 Private-Duty Nursing Long-Term/Custodial Nursing Home Care

+ See All Coverage Details

Premium	Plan Name	Deductible
from $384	Select Advantage HMO 4000	$4,000.00	Select
from $402	Complete HMO 4000 10% with Care Complement	$4,000.00	Select
from $455	Premier Silver Saver PPO 4000	$4,000.00	Select
from $473	Complete PPO Plus 4000 10% with Care Complement	$4,000.00	Select
from $1,316	HMO 4000 - Flex	$4,000.00	Select

Last Name

Location/Distance

Please select the correct zip

Jackie, Fantes

Loretta, Chou

Stephen, Simon

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

What Is the Silver Plan?
ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.
How are Silver Plans different than other Obamacare health plans?
The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.
How much does a Silver Plan cost?
The monthly premium for a Silver Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.
When Can I Enroll in a Silver Plan?
The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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Income
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PPO 4000 - 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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PPO 4000 - Flex

Apply For This Plan

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

Similar Plans

Physician Finder

Related Articles

Related Searches

Silver plan frequently asked questions (FAQ)

What Is the Silver Plan?

How are Silver Plans different than other Obamacare health plans?

How much does a Silver Plan cost?

When Can I Enroll in a Silver Plan?

Apply For This Plan

Health Plans Found

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