It's easy to use your Harvard Pilgrim HMO

It's easy to use your

Harvard Pilgrim HMO

Welcome to Harvard Pilgrim! We're very happy to have you as a member. To get you started, we've highlighted the basics about your health plan. If you have additional questions or would like more detailed information about your benefits, log on to and click on HPHConnect or consult your Benefit Handbook. You may also call our Member Services Department at 1-888-333-4742, Monday through Friday, 8:00 a.m. - 5:30 p.m., or until 7:30 p.m. on Monday and Wednesday evenings. If you are deaf or hard-of-hearing, please call 1-800-637-8257 for TDD service. We're here to make your health care easier to manage and provide you with coverage you can trust.

Always carry your ID card with you and present it at all doctor, hospital and, Y O U R I D C A R D if covered, pharmacy visits. Your card includes codes specific to your benefits.

How to

This is your member ID number, which

Read Your

is used for all Member Services inquiries as

ID Card:

well as claims payment, billing and

processing.

OV = Office Visit Copayment

(and other copayments if applicable)*

ER = Emergency Room Copayment (waived

if admitted)

THE HARVARD PILGRIM HMO

ID#: HP0000000-00

Name: JOHN Q SAMPLE

Copay: $10OV

$50ER $5 ALLERGY INJ

DEDUCTIBLES: IND $1000 FAM $2000

$10 CHIRO

RX: $5 / 15 / 35

MAIL: $10 / 30 / 105

Allergy Injection Copayment

Chiro = Chiropractic Care Copayment

(listed only if a covered benefit)

If applicable, health plan

deductible amount**

RX = Pharmacy Copayment

(Generic/Select Brand/Non-Select Brand); if applicable, an Rx deductible will also be listed

Mail = Mail Service Copayment

(Generic/Select Brand/Non-Select Brand)

If you have Harvard Pilgrim prescription

coverage, you will see the MedCareTM logo, which represents our network of more than 40,000 participating pharmacies

* Some plans have different copayments for different services. If applicable, these codes equal the following:

OBGYN = Obstetrics/Gynecology PT = Physical Therapy OT = Occupational Therapy ST = Speech Therapy MH/SA = Mental Health/Substance Abuse ** Refer to Schedule of Benefits for deductibles and out-of-pocket maximums.

Need a replacement ID card for you or your dependents? Log on to and go to HPHConnect any time!

DOCTORS' VISITS AND REFERRALS

Having a personal primary care physician makes health care easier for you. In most cases, your PCP will provide or arrange for all the health services you need, treating you when you're sick, and administering preventive screenings, routine check-ups and immunizations.

Your PCP is also the key to ensuring that you get high-quality specialty care if you need it. If you need specialty care that your PCP does not provide, your PCP will refer you to another physician or appropriate medical professional. (Referrals are not necessary for some services. Please check your Benefit Handbook for more information on services that do not require a referral.)

Although there are thousands of physicians that take care of Harvard Pilgrim members, your PCP will send you to a specialist affiliated with his or her own practice. For example, if a visit to a cardiologist is necessary, your doctor will refer you to someone in a local medical practice or hospital with which he or she is personally affiliated. Individual PCPs and groups of PCPs typically develop strong working relationships with particular specialists. This enables the doctors to collaborate more effectively on behalf of their patients and helps ensure excellent communication, appropriate choice of treatment and higher quality care.

Your PCP may occasionally make a referral to a physician outside his or her usual network of specialists, but only if the expertise needed to handle a particular case is not available from a specialist affiliated with his or her own practice.

You play an important role in this process. Whenever you need specialty care, you should feel comfortable discussing the referral process with your doctor, and asking why he or she is recommending a certain specialist.

EMERGENCY CARE

In a medical emergency, you should go to the nearest emergency facility or call 911 (or other local emergency number). Harvard Pilgrim covers all medical emergencies.

A medical emergency is the sudden onset of a condition that requires prompt medical or surgical care to prevent death or serious damage to your health. Examples include symptoms of a heart attack, stroke, loss of consciousness, choking, severe head trauma, convulsions and major blood loss.

In medical emergencies, you do not need a referral from your PCP. If you or a family member covered by your Harvard Pilgrim insurance is hospitalized, you must call your PCP and Harvard Pilgrim's Member Services Department within 48 hours.

STUDENT COVERAGE

Typically when a child over age 19* is attending school, Harvard Pilgrim still covers your child as long as:

he or she is enrolled as a full-time student at an accredited educational institution, and

you provide Harvard Pilgrim with an affidavit verifying the dependent's student status, and

he or she is an unmarried child or step-child under age 25*.

* Please note that some employers set different age limits; check with your employer for specific dependent eligibility information.

Want to learn more about member programs, discounts and benefits? Log on to for information 24 hours a day!

PRESCRIPTIONS

Three-Tier Drug Program If your employer offers prescription coverage through the Harvard Pilgrim HMO, you have a three-tier drug benefit with three levels of payments. Depending on your plan, your payments ? also called "cost-sharing" ? may include a combination of copayments, coinsurance or a deductible. (See the Prescription Drug Coverage brochure for definitions.) This means that, in many cases, you can reduce your out-of-pocket costs by using a drug listed on a lower tier. Our threetier prescription drug program offers coverage of US Food and Drug Administration-approved drugs, with few restrictions. For more information, please log on to (for members, pharmacy section) or call Member Services.

Cost-sharing amounts are listed on your ID card. Tiers are as follows:

Tier 1: Generic Drugs

(lowest copayment or coinsurance amount)

Tier 2: Select Brand

(middle copayment or coinsurance amount)

Tier 3: Non-Select Brand

(highest copayment or coinsurance amount)

Our three-tier prescription benefit encourages discussion between you and your doctor. In most cases, your doctor can prescribe a Tier 1 or Tier 2 drug to effectively treat your condition -- as well as save you money. Should you and your doctor decide that a Tier 3 drug is best for you, we will still cover your medication but at the Tier 3 copayment or coinsurance amount.

Thousands of Drugs Covered Our Web site lists all identified prescription medications and their tier. You may also call Harvard Pilgrim's Member Services Department to learn if a specific medication is covered or to obtain a copy of our drug list.

Thousands of Participating Pharmacies and an Online Drugstore Too! There are thousands of pharmacies in our network, including an online drugstore and major chains such as Brooks, CVS, Kmart, Stop & Shop, Walgreens and Wal-Mart. You may also fill your prescriptions at most local, independent pharmacies. Simply present your Harvard Pilgrim HMO ID card at a participating pharmacy along with your prescription or refill and pay the applicable cost-sharing amount.* To learn if a specific pharmacy is in our network, or to order online, log on to .

Prescriptions by Mail Enjoy the convenience of home delivery for your maintenance medications (prescriptions for ongoing, chronic conditions**). Standard shipping is free and some plans provide lower costsharing amounts for a 90-day supply (when applicable) of Tier 1 or Tier 2 drugs when you purchase them through this program. Cost-sharing amounts are listed on your ID card.

It's easy to use our Mail Service Prescription Drug Program too! Visit "pharmacy program" at for details or request order forms by calling Member Services at 1-888-333-4742.

* Some plans require a pharmacy deductible. Please refer to your Harvard Pilgrim member identification card.

** Prescriptions for which a 90-day supply may not be appropriate, as determined by Harvard Pilgrim, may not be purchased through Mail Service.

WHEN YOU TRAVEL

If you become sick or injured outside of the Harvard Pilgrim service area, i.e., outside of the state that you live in, we cover any unforeseen care you may need. Examples of conditions for which we cover care while you're outside the service area include: earaches, flu, poisoning, broken bones, medical emergencies and prescription drugs (if you have prescription drug coverage).

If it's a medical emergency, you do not have to call your PCP before getting care. However, when possible, call your PCP and he/she will refer you to a physician in the area that you are visiting. If you are hospitalized, you or a family member must call Harvard Pilgrim's Member Services Department and your PCP within 48 hours to notify us of your admission. Your PCP will help to arrange any follow-up care you may need.

Managing your health benefits is now as easy as clicking a mouse!

HPHConnect offers a secure online connection, and a more efficient way to manage your benefits. As a subscriber, you can go to the HPHConnect section of our Web site and:

Select a PCP for yourself or your family members Order replacement ID cards

Update personal information (e.g., address & phone) View benefits information

BILLS & QUESTIONS

As an HMO member, you shouldn't receive bills for covered services from providers contracted with Harvard Pilgrim unless you're enrolled in a Best Buy plan.* If you get a bill, ask your provider's office to bill Harvard Pilgrim on a standard health care claim form and send it to the address listed on the back of your ID card. Please ask your provider to include the patient's name, if not yourself, and the ID number located on your ID card. On occasion, providers will bill for the copayment instead of collecting it at the time of your visit. In these instances, you should send the copayment directly to your provider.

If you have additional questions about billing or are concerned about any services you receive, please let us know. Call Member Services between 8 a.m. and 5:30 p.m., Monday through Friday at 1-888-333-4742. Or, take advantage of our evening hours on Monday and Wednesday from 8:00 a.m. to 7:30 p.m. Our goal is to get your questions answered quickly so that managing your health care is easier for you!

* Members enrolled in plans with deductibles, like the Best Buy HMO, are required to pay for select procedures up until their annual deductible and/or their out-of-pocket maximum is met. For members enrolled in plans with deductibles, please refer to your Schedule of Benefits for applicable billing information.

C Printed on recycled paper

This information refers to plans offered by Harvard Pilgrim Health Care and its affiliates, Harvard Pilgrim Health Care of New England and HPHC Insurance Company.

93 Worcester Street, Wellesley, MA 02481 1-800-848-9995



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