ID: MD0000004736_ X Schedule of s HARVARD PILGRIM LAHEY HEALTH SELECT HMO OUT OF AREA 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 www.harvardpilgrim.org/lahey to determine the tier of Providers in the Harvard Pilgrim-Lahey Health Select Network. This Schedule of s summarizes your s under Harvard Pilgrim Lahey Health Select HMO Out of Area (the Plan) and states the Member amounts that you must pay for Covered s. However, it is only a summary of your benefits. Please see your 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 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 www.harvardpilgrim.org or by calling 1-888-888-4742 ext. 38723. Your Covered s are administered on a Calendar Year basis. MEMBER COST SHARING Members are required to share the cost of the Covered s provided under the Plan. This section describes the payments for which you are responsible, called Member. The tables, set forth below, show the specific Member amounts for the different services covered by the Plan. Your Member will depend upon the type of service provided and the location the service is provided in, as listed in this Schedule of s. 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 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 when EFFECTIVE DATE: 01/01/2018 SCHEDULE OF BENEFITS 1
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 s: 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 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 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 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 www.harvardpilgrim.org/lahey. You may also obtain a paper copy of the directory, free of charge, by calling Harvard Pilgrim s Member Services Department at 1 888 333 4742. 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 Features: Coinsurance and Copaymentsj Adult Primary Care Copaymentj : See the benefits below $20 Copayment : $20 Copayment Pediatric (up to age 19) Primary Pediatric (up to age 19)j $20 Copayment $20 Copayment Adult Care Copaymentj : $80 Copayment $20 Copayment $90 Copayment SCHEDULE OF BENEFITS 2
General Features: : : Pediatric (up to age 19) Care Copaymentj Deductiblesj Deductible Rolloverj Out-of-Pocket Maximumj Includes all Member except charges for prescription drugs. : None None $1,500 per Member per Calendar Year $3,000 per family per Calendar Year None $3,000 per Member per Calendar Year $6,000 per family per Calendar Year Acupuncture Treatment for Injury or Illnessj Not covered Ambulance Transportj Emergency ambulance transport Non-emergency ambulance transport Autism Spectrum Disorders Treatmentj Applied Behavior Analysis Tier 1 Primary $20 No benefit limit applies to this service. Chemotherapy and Radiation Therapyj No Charge No Charge $40 Copayment Dental Servicesj Extraction of teeth impacted in bone Tier 1 Primary $20 (performed in a physician s office) Preventive Dental Care for children Tier 1 Primary $20 (up to the age of 13) - 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 Handbook for the details of your coverage. SCHEDULE OF BENEFITS 3
Dialysisj Non hospital based dialysis services $50 Copayment Hospital based dialysis services $50 Copayment Durable Medical Equipmentj Durable Medical Equipment Blood Glucose Monitors, Infusion Devices and Insulin Pumps (including supplies) Oxygen and Respiratory Equipment Early Intervention Servicesj Emergency Admission Servicesj Tier 1 Primary $20 Emergency Room Carej $200 Copayment 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 Limited to $2,000 per hearing aid every 36 months, for each hearing impaired ear Home Health Carej Please Note: If your Home Health Care services include the administration of drugs, please see the benefit for Medical Drugs for Member details. Hospice Outpatient j Hospital Inpatient Servicesj Acute Hospital Care 20% Coinsurance after Deductible has been met Inpatient Maternity Care 20% Coinsurance after Deductible has been met Inpatient Routine Nursery Care Inpatient Rehabilitation Limited to 60 days per calendar year Skilled Nursing Facility Limited to 100 days per calendar year SCHEDULE OF BENEFITS 4
Infertility Services and Treatments (see the Handbook for details)j Consultations, Evaluations and Your Member 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 s. For example, for services provided by a physician, see Physician Infertility Treatment (as outlined in your Handbook) Laboratory and Radiology Servicesj Physician and non hospital based laboratory and x-rays Hospital based laboratory and x-rays Physician and non hospital based high end radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) Hospital based high end radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) and Other Professional Office Visits. 20% Coinsurance after Deductible has been met No Charge No Charge No Charge Low Protein Foodsj Limited to $5,000 per Calendar Year No Charge No Charge 20% Coinsurance after Deductible has been met Maternity Care - Outpatient j Routine outpatient prenatal and postpartum care Routine prenatal and postpartum care is usually received and billed from the same Provider as a single or bundled service. Different Member may apply to any specialized or non-routine service that is billed separately from your routine outpatient prenatal and postpartum care. For example, Member for services provided by a specialist is listed under Physician and Other Professional Office Visits and Member for an ultrasound billed as a specialized or non-routine service is listed under Laboratory and Radiology Services. Medical Drugs (drugs that cannot be self-administered)j Medical drugs received in a doctor s office or other outpatient facility Medical drugs received in the home Please Note: Your Employer Group also provides a separate outpatient prescription drug plan through CVS Caremark. That benefit provides coverage for most prescription drugs purchased at an outpatient pharmacy. Some medical drugs received in a physician s office or outpatient facility may be provided under your CVS Caremark outpatient prescription drug benefit. Please contact CVS Caremark or the plan materials provided by your Employer Group for information on your costs for outpatient prescription drugs. Medical Formulas j No Charge Mental Health Care (Including the Treatment of Substance Use Disorders)j Inpatient services (Continued on next page) SCHEDULE OF BENEFITS 5
Mental Health Care (Including the Treatment of Substance Use Disorders) (Continued) Intermediate services Acute residential treatment (including detoxification), crisis stabilization and in-home family stabilization Intensive outpatient programs, partial hospitalization and day treatment programs for mental health and drug and alcohol rehabilitation services Outpatient group therapy Tier 1 Primary $20 Outpatient treatment, including Tier 1 Primary $20 individual therapy, outpatient detoxification and medication management Outpatient methadone maintenance Not covered Outpatient psychological testing and neuropsychological assessment Performed by a Licensed Mental Health Professional Performed by a Neurologist or other medical specialist. Ostomy Suppliesj Tier 1 Primary $20 Adults: Tier 1 $30 age 19): Tier 1 $30 Adults: Tier 2 $30 age 19): Tier 2 $30 Adults: Tier 3 $90 age 19): Tier 3 $30 Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwise listed in this Schedule of s.)j Routine examinations for preventive care, including immunizations Adults: Tier 3 Primary Care Copayment: $80 for age 19) (Continued on next page) SCHEDULE OF BENEFITS 6
Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwise listed in this Schedule of s.) (Continued) Not all services you receive during your routine exam are covered at no charge. Only preventive services designated under the Patient Protection and Affordable Care Act (PPACA) are covered at no charge. Other services not included under PPACA may be subject to additional cost sharing. For the current list of preventive services covered at no charge under PPACA, please see the Preventive Services notice on our website at www.harvardpilgrim.org. Please see Laboratory and Radiology Services for the Member that applies to diagnostic services not included on this list. Consultations, evaluations and sickness and injury care Office based treatments and procedures, including, but not limited to administration of injections, allergy treatments, casting, suturing and the application of dressings, genetic counseling, non-routine foot care, pregnancy testing, and surgical procedures Administration of allergy injections Preventive Services and Testsj Adults: Primary $20 age 19): Primary $20 Adults: Specialty and $30 age19): : Specialty and $30 $15 Copayment Adults: Primary $20 age 19): Primary $20 Adults: Specialty and $30 age19): : Specialty and $30 Adults: Primary $80 age 19): Primary $20 Adults: Specialty and $90 age19): : Specialty and $30 Under federal law, many preventive services and tests are covered with no Member, including preventive colonoscopies, [and ]certain labs and x-rays[, voluntary sterilization for women, and all FDA approved contraceptive devices]. For a complete list of covered preventive services, please see the Preventive Services Notice on our website at www.harvardpilgrim.org. You may also get a copy of the Preventive Services notice by calling the Member Services Department at 1 888 333 4742. Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordance with Federal guidance. Prosthetic Devicesj SCHEDULE OF BENEFITS 7
Rehabilitation and Habilitation Services - Outpatientj Cardiac Rehabilitation Pulmonary rehabilitation therapy Speech-Language and Hearing Services Adults: $50 Copayment per visit Occupational therapy limited to 30 visits per Calendar Year Physical therapy limited to 30 visits per Calendar Year Please note: Outpatient physical and occupational therapy is covered to the extent Medically Necessary for: (1) children under the age of three and (2) the treatment of Autism Spectrum Disorders. Pediatrics (up to age 19): $30 Copayment per visit Adults: $50 Copayment per visit Pediatrics (up to age 19): $30 Copayment per visit Outpatient physical and occupational therapy is not subject to the limit listed above and is covered to the extent Medically Necessary for: (1) children under the age of three and (2) the treatment of Autism Spectrum Disorders. Scopic Procedures - Outpatient Diagnostic and Therapeutic j Colonoscopy, endoscopy and sigmoidoscopy Spinal Manipulative Therapy (including care by a chiropractor)j Limited to 12 visits per Calendar Year Surgery Outpatient j Urgent Care Servicesj Convenience care clinic Your Member will depend upon where the service is provided and the tier placement of the provider rendering services, as listed in this Schedule of s. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services. $50 Copayment $50 Copayment 20% Coinsurance after Deductible has been met Tier 1 Primary $20 Urgent care clinic (including hospital urgent care clinic) $120 Copayment Please Note: Additional Member may apply. Please refer to the specific benefit in this Schedule of. For example, if you have an x-ray or have blood drawn, please refer to Laboratory and Radiology Services. SCHEDULE OF BENEFITS 8
Vision Servicesj Routine eye examinations -limited to 1 exam per Calendar Year Adults: Tier 3 $90 for age 19) Vision hardware for special conditions No Charge (see the Handbook for details) Voluntary Sterilization in a Physician s Officej Your Member will depend upon where the service is provided and the tier placement of the provider rendering services, as listed in this Schedule of s. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Physician and Other Professional Office Visits. For inpatient hospital care, see Hospital Inpatient Services Voluntary Termination of Pregnancyj Your Member will depend upon where the service is provided and the tier placement of the provider rendering services, as listed in this Schedule of s. For example, for a service provided in an outpatient surgical center, see Surgery Outpatient. For services provided in a physician s office, see Office based treatments and procedures. For inpatient hospital care, see Hospital Inpatient Services Wigs and Scalp Hair Prostheses j When needed as a result of any form of cancer or leukemia, alopecia areata, alopecia totalis or permanent hair loss due to injury Limited to $350 per Calendar Year (see the Handbook for details) SCHEDULE OF BENEFITS 9
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