How it Works: The HMO Plus Out of Area Plan

With this plan, you’re in control of your health care dollars. You choose where to receive your medical care. When you receive care at a Tier 1 or Tier 2 provider, you pay less.

You’re eligible to enroll in this plan if you live 20 or more miles from a Tier 1 BILH primary care provider (PCP) and you live within Harvard Pilgrim’s enrollment area (MA, ME, NH, CT, and certain areas of RI, VT and NY).

Features

• You choose a PCP for your medical care.

• The HMO Plus Out of Area Plan has a three-tier provider network design.

• When you choose a Tier 1 or Tier 2 provider, most services will be covered in full or with a lower copayment amount.

• Tier 3 include a deductible and coinsurance.

• Emergency Room visits are the same across all three tiers.

• When you travel and need unforeseen care, your coverage travels with you.

Which providers and can I visit? With this plan you can visit only those providers (doctors and other medical professionals) and hospitals that belong to the HMO Plus Out of Area Plan network, except in a medical emergency. (See page 4 for a list of hospitals and their tiers.)

Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company. HOW IT WORKS, continued

Do I need a primary care provider (PCP)? someone needs to notify your PCP or Harvard Pilgrim Yes. Please choose an HMO Plus Out of Area Plan PCP as soon as reasonably possible. Your attending physician at the time you enroll. If you do not, Harvard Pilgrim will may do this, or you can ask someone to do it for you. assign one to you. You must have your PCP provide your care (except in emergencies) and give you referrals for Do I have coverage when I’m traveling? most kinds of specialty care for the plan to provide You have coverage for unexpected or unforeseen care coverage for the service. Make sure any PCP you (e.g., earache, flu or sprain) when you’re traveling outside choose has admitting privileges at HMO Plus the state where you live. Otherwise, except in a medical Out of Area Plan hospitals. emergency, you must receive care from HMO Plus Out of Area Plan providers and hospitals My family and I already have PCPs that we like. Can we continue to see them? What about my prescription drug coverage? Yes, if your PCPs are part of the HMO Plus Out of Area Harvard Pilgrim does not administer your prescription Plan network. To find out, use the HMO Plus Out of Area drug coverage. Caremark administers the prescription Plan provider directory at harvardpilgrim.org/bilh. Make drug plan for BILH employees. Prescriptions may be sure your PCPs have admitting privileges at HMO Plus filled at your local pharmacy (i.e., CVS or Walgreens) Out of Area Plan hospitals. with a copay. You may also fill your prescriptions at the Beth Israel Deaconess Medical Center (BIDMC) pharmacy, Do I need referrals to visit specialists? located in the Shapiro building lobby, and save money: Yes, you need your PCP’s referral for most visits to HMO a $5 copay for up to 30-day supplies and a $10 copay Plus Out of Area Plan specialists. You can get routine for up to 90-day supplies. If you have questions about eye exams and most kinds of gynecological care without your pharmacy coverage, please contact Caremark your PCP’s referral, but make sure you see HMO Plus at (855) 303-3980. If you have questions about the Out of Area Plan providers for these services. BIDMC pharmacy, please call (617) 667-6400 or email [email protected]. What about going to the ? If you need tests or surgery at a hospital, your HMO Confidential health support Plus Out of Area Plan PCP or specialist must refer you Whether you need to talk to someone about a recent to a HMO Plus Out of Area Plan hospital. The only time health diagnosis or want tips for maintaining a healthier you don’t need a referral to go to the hospital is in lifestyle, BILH employees have a resource and advocate in a medical emergency. Harvard Pilgrim nurse care manager Corrine Palladino, RN, CCM. Call or email Corrine for personalized, confidential Can I go to providers and hospitals that are not and free health support. part of the HMO Plus Plan network? • PHONE: (617) 509-9191 (weekdays between No. Except in a medical emergency, if you go to a 8:00 a.m. and 5 p.m.) provider or hospital that is not part of the HMO Plus Out of Area Plan network, you will be responsible for • EMAIL: [email protected] paying all charges. Fitness Reimbursement What do I do in an emergency? You and your covered dependents who belong In a medical emergency (e.g., heart attack, stroke, to a qualified health and fitness club for four choking, loss of consciousness or seizures), just call months in a calendar year can receive up to $150 911 or go straight to the nearest emergency room. fitness reimbursement each calendar year. You have coverage for medical emergencies no matter where you are. If you are admitted to the hospital, The HMO Plus Out of Area Plan cost-sharing highlights1

Tier 1 and Tier 2 Tier 3 Annual Deductible None $1,500 per individual/$3,000 per family Annual Out-of-Pocket Maximum $3,500 per individual/$7,000 per family Inpatient Hospital • Adult medical/surgical No charge Deductible, then 40% coinsurance • Pediatric (up to age 19) No charge Deductible, then 40% coinsurance medical/surgical • Maternity No charge Deductible, then 40% coinsurance • Mental health/substance use No charge Outpatient Hospital • Adult day surgery No charge Deductible, then 40% coinsurance • Pediatric (up to age 19) No charge Deductible, then 40% coinsurance day surgery Emergency Room $200 copay (waived if admitted) Urgent Care (only hospital and HPHC participating urgent $35 copay $125 copay care center) Physician’s Office • Preventive adult and pediatric care No charge (including GYN) • Adult care (including GYN) PCP: $25 copay PCP: $85 copay Specialist: $35 copay Specialist: $95 copay • Pediatric care (up to age 19, PCP: $25 copay PCP: $85 copay including GYN) Specialist: $35 copay Specialist: $95 copay • Routine maternity (pre/post natal) No charge • Mental health/substance use $25 copay X-rays and Lab Tests High-tech Imaging • Hospital-affiliated No charge Deductible, then 40% coinsurance • Non-hospital-affiliated No charge $75 copay Routine Eye Exams $95 copay $35 copay (one exam every 12 months) ($35 copay for children up to age 19) Short-term Therapy – Outpatient Physical and occupational: combined limit of 72 visits per calendar year • Hospital- and non-hospital $65 copay ($35 copay for children $35 copay affiliated up to age 19) Skilled Nursing Facility No charge (100 days per calendar year) Chiropractic Care (up to 12 visits) $35 copay $65 copay

1 Please refer to the Schedule of Benefits and Benefit Handbook for details and a complete list of benefits. The Schedule of Benefits and Benefit Handbook govern in any case in which the information in this document is different. BILH HMO Plus Plan Hospitals Please use the BILH HMO Plus Plan provider directory at harvardpilgrim.org/bilh to find out whether your PCP and specialists participate in the network and what tier they’re in.

Massachusetts – Tier 1 Hospitals – Tier 3 Hospitals Connecticut – Tier 3 Hospitals New Hampshire – Tier 2 Hospitals (cont.) Anna Jaques Hospital (cont.) Bridgeport Hospital Beth Israel Deaconess Greenwich Hospital Huggins Hospital Medical Center Hartford Hospital Monadnock Community Hospital Beth Israel Deaconess Hospital- Good Samaritan Medical Center Lawrence & Memorial Hospital New London Hospital Needham Campus Hallmark Health Systems (Lawrence MidState Medical Center Parkland Medical Center Beth Israel Deaconess Hospital- Memorial Hospital and Melrose The Hospital of Central Connecticut Southern NH Medical Center Milton Wakefield Hospital) The William W. Backus Hospital Speare Memorial Hospital Beth Israel Deaconess Hospital- Holy Family Hospital Windham Community Hospital St. Joseph Hospital Plymouth Holy Family Hospital - Merrimack The Cheshire Medical Center Lahey Hospital and Medical Center Valley Campus Yale-New Haven Hospital Lowell General Hospital Maine – Tier 2 Hospitals New Hampshire – Tier 3 Hospitals New England Baptist Hospital Martha’s Vineyard Hospital Bridgton Hospital Androscoggin Valley Hospital Northeast Hospital Corporation Massachusetts Eye and Ear Infirmary Calais Regional Hospital Concord Hospital (Addison Gilbert Hospital Massachusetts General Hospital* Cary Medical Center Elliot Hospital and Beverly Hospital) Metrowest Medical Center Down East Community Hospital Exeter Hospital (Framingham Union Hospital Franklin Memorial Hospital Lakes Region General Hospital and Leonard Morse Hospital) Littleton Regional Hospital Massachusetts – Tier 2 Hospitals Houlton Regional Hospital Milford Regional Medical Center, Inc. Portsmouth Regional Hospital LincolnHealth Morton Hospital and Medical Center Mary Hitchcock Memorial Hospital Baystate Franklin Medical Center MaineGeneral Medical Center Cottage Hospital The Memorial Hospital Baystate Noble Hospital Mayo Regional Hospital Newton Wellesley Hospital Upper Connecticut Valley Hospital Baystate Wing Hospital Mid Coast Hospital Northshore Medical Center Valley Regional Hospital (Salem Hospital and Union Hospital) Millinocket Regional Hospital Weeks Medical Center Boston Children’s Hospital Mount Desert Island Hospital Wentworth-Douglass Hospital Saint Anne’s Hospital Northern Light A.R. Gould Hospital Charlton Memorial Hospital Northern Light Blue Hill Hospital Rhode Island – Tier 2 Hospitals Fairview Hospital St. Elizabeth’s Medical Center Northern Light C.A. Dean Hospital Newport Hospital Floating Hospital for Children The Shriner’s Hospital for Children Northern Light Inland Hospital Our Lady of Fatima Hospital (Boston and Springfield) at Northern Light Maine Coast Hospital South County Hospital Tufts Medical Center Harrington Memorial Hospital Northern Light Mercy Hospital Rhode Island – Tier 3 Hospitals Health Alliance-Clinton Hospital UMass Memorial Medical Center (Hahnemann, Memorial and Northern Light Sebasticook Kent County Memorial Hospital (Burbank, Leominster & University Campuses) Valley Hospital Miriam Hospital Clinton Campuses) Northern Maine Medical Center Rhode Island Hospital Heywood Hospital Connecticut – Tier 2 Hospitals Penobscot Bay Medical Center Roger Willams Medical Center , Inc. Bristol Hospital Penobscot Valley Hospital Westerly Hospital Lawrence General Hospital The Charlotte Hungerford Hospital Redington-Fairview General Hospital Women and Infants Hospital Marlborough Hospital Connecticut Children’s Rumford Hospital Medical Center Vermont – Tier 2 Hospitals Mercy Medical Center Southern Maine Health Care Danbury Hospital Brattleboro Memorial Hospital Nashoba Valley Medical Center St. Joseph Hospital Day Kimball Hospital Central Vermont Medical Center St. Mary’s Regional Medical Center Griffin Hospital Gifford Medical Center Signature Healthcare Brockton Stephens Memorial Hospital Hospital John Dempsey Hospital Grace Cottage Hospital Waldo County General Hospital St. Luke’s Hospital Johnson Memorial Medical Center Mount Ascutney Hospital York Hospital Sturdy Memorial Hospital Middlesex Hospital and Health Center The Cambridge Health Alliance Milford Hospital Maine – Tier 3 Hospitals North Country Hospital Tobey Hospital Norwalk Hospital Central Maine Medical Center Northeastern Vermont Regional Hospital Prospect Manchester Hospital Northern Light Eastern Maine Massachusetts – Tier 3 Hospitals Porter Medical Center Prospect Rockville Hospital Medical Center Baystate Medical Center Maine Medical Center Springfield Hospital Sharon Hospital Brigham and Women’s Hospital* Southwestern Vermont Medical Center Saint Francis Hospital New Hampshire – Tier 2 Hospitals Brigham and Women’s University of Vermont Medical Center Faulkner Hospital & Medical Center Alice Peck Day Memorial Hospital Saint Mary’s Hospital Catholic Medical Center New York – Tier 2 Hospitals St. Vincent’s Medical Center Cottage Hospital Champlain Valley Physicians Hospital Cooley Dickinson Hospital Stamford Hospital Franklin Regional Hospital Elizabethtown Community Hospital Dana-Farber Cancer Institute Waterbury Hospital Frisbie Memorial Hospital

* Includes satellite facilities and ancillary services.

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