Harvard Pilgrim Health Care

ElevateHealth HMO Gold 1500

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Exclusions: Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Stay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 15.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: No Charge Covered: Covered Benefit Explanation: Routine Prenatal and Postnatal Care are covered in full.

Vision

Routine Eye Exams For Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: For Members under the age of 19

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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