Harvard Pilgrim – Lahey Health Select HMO ScheduleofBenefits

ID: MD0000004734_

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Schedule of Benefits

Harvard Pilgrim ¨C Lahey Health Select HMO

MASSACHUSETTS

Please Note: In this plan, Member¡¯s have access to network benefits only from the providers

in the Harvard Pilgrim-Lahey Health Select network. This network includes a tiered provider

network. In this plan, Members pay different levels of Copayments or Coinsurance depending

on the tier of the provider delivering a covered service or supply. Please consult the

Harvard Pilgrim-Lahey Health Select Provider Directory or visit the provider search tool at

laheyhealth to determine the tier of Providers in the Harvard

Pilgrim-Lahey Health Select Network.

This Schedule of Benefits summarizes your Benefits under Harvard Pilgrim ¨C Lahey Health Select

HMO (the Plan) and states the Member Cost Sharing amounts that you must pay for Covered

Benefits. However, it is only a summary of your benefits. Please see your Benefit Handbook for

detailed information on benefits covered by the Plan and the terms and conditions of coverage.

This plan does not provide coverage for outpatient prescription drugs. Your coverage for

prescription drugs is administered by a third party named CVS Caremark. If you have questions

regarding your pharmacy coverage, CVS Caremark can be reached at 1-866-329-3056.

In a Medical Emergency you should go to the nearest emergency facility or call 911 or other

local emergency access number. Your emergency room Member Cost Sharing is listed in the

tables below.

Clinical Review Criteria

We use clinical review criteria to evaluate whether certain services or procedures are Medically

Necessary for a Member¡¯s care. Members or their practitioners may obtain a copy of our clinical

review criteria on our website at or by calling 1-888-888-4742 ext. 38723.

Your Covered Benefits are administered on a Calendar Year basis.

MEMBER COST SHARING

Members are required to share the cost of the Covered Benefits provided under the Plan. This

section describes the payments for which you are responsible, called Member Cost Sharing. The

tables, set forth below, show the specific Member Cost Sharing amounts for the different services

covered by the Plan.

Your Member Cost Sharing will depend upon the type of service provided and the location the

service is provided in, as listed in this Schedule of Benefits. For example, for services provided in

a doctor¡¯s office, see ¡°Physician and Other Professional Office Visits.¡± For services provided in a

hospital emergency room, see ¡°Emergency Room Care,¡± and for outpatient surgical procedures,

please see "Surgery - Outpatient."

PREVENTIVE SERVICES

No Member Cost Sharing applies to certain preventive services when received by an adult from a

Tier 1 or Tier 2 provider. For pediatrics (up to age 19), there is no Member Cost Sharing when

EFFECTIVE DATE: 01/01/2019

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HARVARD PILGRIM ¨C LAHEY HEALTH SELECT HMO - MASSACHUSETTS

received from a Tier 1, Tier 2 or Tier 3 provider. These services are summarized below and further

described in the tables later in this Schedule of Benefits:

? Preventive gynecological examinations

?

Immunizations

?

Specified Preventive services and tests

?

Routine well physical examinations (including well child care, vision and auditory screening

for children, and health education)

TIERED PROVIDERS

Most hospitals and physicians covered by the Plan are placed into one of three benefit levels or

¡°tiers¡±. Member Cost Sharing for these providers depends upon the tier in which a provider is

placed. Tier 1 is the lowest cost tier. Tier 2 is the medium cost tier. Tier 3 is the highest cost

tier. Please see your Benefit Handbook for more information on how hospitals and physicians

are tiered under the Plan. Only acute care hospitals, Primary Care Providers (PCPs) and medical

specialists are assigned to one of three tiers. All other covered providers are assigned to Tier 1.

You can lower your out-of-pocket cost by selecting the physicians and hospitals in the lower cost

tiers. The tables set forth below list the Member Cost Sharing for each type of tiered service. The

Plan¡¯s Provider Directory lists all Plan Providers and their tier. You can access the Provider Directory

at . You may also obtain a paper copy of the directory, free of , by calling

Harvard Pilgrim¡¯s Member Services Department at 1¨C888¨C333¨C4742.

Please note: When you choose a PCP, it is important to consider the tier of the hospital that your

PCP uses. For example, a Tier 1 PCP may admit patients to a Tier 2 or to a Tier 3 Hospital.

General Cost Sharing Features:

Tier 1 Member

Cost Sharing:

Tier 2 Member

Cost Sharing:

Tier 3 Member

Cost Sharing:

Coinsurance and Copaymentsj

See the benefits table below

Adult ¨C Primary Care Copaymentj

Your Plan has a

Your Plan has a

$20 Copayment

$40 Copayment

per visit

per visit

Pediatric (up to age 19) ¨C Primary Care Copayment ¨C j

Your Plan has a

Your Plan has a

$20 Copayment

$20 Copayment

per visit

per visit

Adult ¨C Specialty and Hospital Based Care Copaymentj

Your Plan has a

Your Plan has a

$50 Copayment

$30 Copayment

per visit

per visit

Pediatric (up to age 19) ¨C Specialty and Hospital Based Care Copaymentj

Your Plan has a

Your Plan has a

$30 Copayment

$30 Copayment

per visit

per visit

Your Plan has a

$80 Copayment

per visit

Your Plan has a

$20 Copayment

per visit

Your Plan has a

$90 Copayment

per visit

Your Plan has a

$30 Copayment

per visit

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HARVARD PILGRIM ¨C LAHEY HEALTH SELECT HMO - MASSACHUSETTS

General Cost Sharing Features:

Tier 1 Member

Cost Sharing:

Tier 2 Member

Cost Sharing:

None

$500 per Member

per Calendar Year

$1,000 per family

per Calendar Year

Tier 3 Member

Cost Sharing:

Deductiblesj

$1,500 per

Member per

Calendar Year

$3,000 per family

per Calendar Year

Please Note: The maximum amount you will pay for a Deductible in a Calendar Year will not exceed the

Tier 3 Deductible amounts. For Example, if you have satisfied your Tier 2 Member Deductible of $500 and

then receive Covered Benefits from a Tier 3 Provider that apply toward your Tier 3 Deductible, you will

not be required to pay the full $1,500 Tier 3 Deductible. $500 has already been satisfied when the Tier

2 Deductible was met.

Deductible Rolloverj

None

Out-of-Pocket Maximumj

Includes all Member Cost Sharing except

charges for prescription drugs.

$3,000 per Member per Calendar Year

$6,000 per family per Calendar Year

Tier 1 Member

Cost Sharing

Acupuncture Treatment for Injury or Illnessj

Not covered

Benefit

Tier 2 Member

Cost Sharing

Tier 3 Member

Cost Sharing

Ambulance Transportj

Emergency ambulance transport

No charge

Non-emergency ambulance transport

No charge

Autism Spectrum Disorders Treatmentj

Applied Behavior Analysis

Tier 1 Primary Care Copayment: $20 per visit

Chemotherapy and Radiation Therapyj

No charge

Dental Servicesj

Extraction of teeth impacted in bone

Tier 1 Primary Care Copayment: $20 per visit

(performed in a physician¡¯s office)

Preventive Dental Care for children

Tier 1 Primary Care Copayment: $20 per visit

(up to the age of 13) ¨C limited to 2

preventive dental exams per Calendar

Year, only the following services are

included: cleaning, flouride treatment,

teaching plaque control and x-rays.

Important Notice: Coverage of Dental Care is very limited. Please see your Benefit Handbook for

the details of your coverage.

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HARVARD PILGRIM ¨C LAHEY HEALTH SELECT HMO - MASSACHUSETTS

Benefit

Dialysisj

Non¨Chospital based dialysis services

Hospital based dialysis services

Tier 1 Member

Cost Sharing

Tier 2 Member

Cost Sharing

Tier 3 Member

Cost Sharing

No charge

$35 Copayment

per visit

$50 Copayment

per visit

No charge for

Pediatrics (up to

the age of 19)

$35 Copayment

per visit

$50 Copayment

per visit

No charge

No charge for

Pediatrics (up to

the age of 19)

Durable Medical Equipmentj

Durable Medical Equipment

Blood Glucose Monitors, Infusion

Devices and Insulin Pumps (including

supplies)

Oxygen and Respiratory Equipment

No charge

No charge

No charge

Early Intervention Servicesj

Tier 1 Primary Care Copayment: $20 per visit

Emergency Admission Servicesj

No charge

Emergency Room Carej

$200 Copayment per visit

This Copayment is waived if admitted to the hospital directly from the emergency room.

Hearing Aids (for Members up to the age of 22)j

No charge

¨C Limited to $2,000 per hearing aid

every 36 months, for each hearing

impaired ear

Home Health Carej

No charge

Please Note: If your Home Health Care services include the administration of drugs, please see the benefit

for ¡°Medical Drugs¡± for Member Cost Sharing details.

Hospice ¡ª Outpatient j

No charge

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HARVARD PILGRIM ¨C LAHEY HEALTH SELECT HMO - MASSACHUSETTS

Benefit

Hospital ¨C Inpatient Servicesj

Acute Hospital Care

Tier 1 Member

Cost Sharing

Tier 2 Member

Cost Sharing

Tier 3 Member

Cost Sharing

No charge

$500 Copayment

per admission

after Deductible

has been met

20% Coinsurance

after Deductible

has been met

Inpatient Maternity Care

No charge

Inpatient Routine Nursery Care

No charge

No charge

No charge for

Pediatrics (up to

age 19)

No charge

20% Coinsurance

after Deductible

has been met

Inpatient Rehabilitation ¨C limited to 60

days per calendar year

Skilled Nursing Facility ¨C limited to 100

No charge

days per calendar year

Infertility Services and Treatments (see the Benefit Handbook for details)j

Consultations, Evaluations and

Your Member Cost Sharing will depend upon the types of

Laboratory Tests

services provided and the tier placement of the provider

rendering services, as listed in this Schedule of Benefits. For

example, for services provided by a physician, see ¡°Physician

and Other Professional Office Visits.¡±

20% Coinsurance

No charge

Infertility Treatment (as outlined in your No charge

after Deductible

Benefit Handbook)

has been met

Laboratory, Radiology and Other Diagnostic Servicesj

Physician and non¨Chospital based

No charge

laboratory, radiology, genetic testing

and other diagnostic services

No charge

Hospital based laboratory, radiology,

genetic testing and other diagnostic

services

Physician and non¨Chospital based high

No charge

$75 Copayment

$75 Copayment

end radiology (CT scans, PET scans, MRI

per visit

per visit

and MRA, and nuclear medicine services)

No charge for

No charge for

Pediatrics (up to

Pediatrics (up to

age 19)

age 19)

20%

Coinsurance

No charge

Hospital based high end radiology (CT

$75 Copayment

after Deductible

scans, PET scans, MRI and MRA, and

per visit after

has been met

nuclear medicine services)

Deductible has

been met

No charge for

Pediatrics (up to

age 19)

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