PPO HSA 5000 - Flex Plan Details for 2021- HealthPocket

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Zip Code02128
Applicant9/22/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NamePPO HSA 5000 - Flex
Plan IDhhs-95878MA0180003
Plan Year2021
Insurance ProviderHarvard Pilgrim
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$5,000
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$60 Copay after deductible
Specialist Visit$150 Copay after deductible
Laboratory Outpatient and Professional Services$25 Copay after deductible
X-rays and Diagnostic Imaging$150 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$500 Copay after deductible
Deductible - Family$10000 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs$5 Copay after deductible
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://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$1500 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1500 Copay per Stay after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance Service$250 Copay after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$1500 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$60 Copay after deductible
Mental/Behavioral Health Inpatient Services$1500 Copay per Stay after deductible
Substance use disorder outpatient services$60 Copay after deductible
Substance use disorder inpatient services$1500 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 ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
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 BenefitsPreventive Care/Screening/Immunization
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 BenefitsCosmetic Surgery
Private-Duty Nursing
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $372Select Advantage HMO 5000$5,000.00Select
from $408Direct Care Bronze Deductible 5000 Low$5,000.00Select
from $413PPO HSA 5000 - Flex$5,000.00Select
from $464Advantage HMO 5000$5,000.00Select
from $474Select Care Bronze Deductible 5000 Low$5,000.00Select
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Jackie Fantes, MD
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  • Phone Number
    (617) 569-5800
  • Office Locations
    10 Gove St
    East Boston, MA 02128
10 Gove St East Boston MA, 02128

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HealthPocket.com is a free information source. 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. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.