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Massachusetts

The Harvard Pilgrim Best Buy ChoiceNet℠℠℠ HMOSummary of Benefits and Coverage: What this Plan Covers & What You Pay For CoveredServices

Coverage Period: 09/01/2020 — 08/31/2021Coverage for: Individual + Family | Plan Type: HMO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how youand the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called thepremium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of thecomplete terms of coverage, http://www.harvardpilgrim.org/LGsampleEOC. For general definitions of common terms, such asallowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary atwww.healthcare.gov/sbc-glossary or call 1-888-333-4742 to request a copy.

Important Questions Answers Why this mattersWhat is the overalldeductible?

Tier 1 Providers: $0Tier 2 Providers: $1,000 member / $2,000 familyTier 3 Providers: $2,000 member / $4,000 familyBenefits are administered on a Plan Year basis.

Generally you must pay all the costs up to the deductible amountbefore this plan begins to pay. If you have other family memberson the policy, they have to meet their own individual deductibleuntil the overall family deductible amount has been met.

Are there servicescovered before youmeet your deductible?

Yes. Preventive care, provider office visits,prescription drugs and routine eye exams are coveredbefore you meet your deductible.

This plan covers some items and services even if you haven’t yetmet the deductible amount. But, a copayment or coinsurancemay apply.

Are there otherdeductibles for specificservices?

No. You don’t have to meet deductibles for specific services.

What is theout–of–pocket limitfor this plan?

$5,450 member / $10,900 familySeparate out-of-pocket limit applies to Pharmacy, see“If you need drugs to treat your illness or condition”.

The out-of-pocket limit is the most you could pay in a yearof covered services. If you have other family members in thisplan, they have to meet their own out-of-pocket limit until theoverall family out-of-pocket limit has been met.

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Important Questions Answers Why this mattersWhat is not included inthe out–of–pocket limit?

Prescription drugs, premiums, balance-billingcharges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count towardthe out–of–pocket limit.

Will you pay less if youuse a network provider?

Yes. See https://www.harvardpilgrim.org/public/find-a-provider or call 1-888-333-4742 for a list ofpreferred providers.

This plan uses a provider network. You will pay less if youuse a provider in the plan’s network. You will pay the most ifyou use an out-of-network provider, and you might receive abill from a provider for the difference between the provider’scharge and what your plan pays (balance-billing). Be aware,your network provider might use an out-of-network providerfor some services (such as lab work). Check with your providerbefore you get services.

Do you need a referral tosee a specialist?

Yes, some exceptions apply. This plan will pay some or all of the costs to see a specialistfor covered services but only if you have a referral before yousee the specialist.

All copayment and coinsurance cost shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

CommonMedical Event

Services You MayNeed Network Provider

(You will pay the least)

Out-of-NetworkProvider

(You will paythe most)

Limitations,Exceptions, &Other ImportantInformation

Primary care visitto treat an injury orillness

Tier 1 Primary Care: $20 copay/ visit; deductible doesnot applyTier 2 Primary Care: $30 copay/ visit; deductible doesnot applyTier 3 Primary Care: $50 copay/ visit; deductible doesnot apply

Not covered None

Specialist visit Tier 1 Specialty & Hospital Based: $50 copay / visit;deductible does not applyTier 2 Specialty & Hospital Based: $50 copay/ visit;deductible does not applyTier 3 Specialty & Hospital Based: $50 copay/ visit;deductible does not apply

Not covered None

If you visita health careprovider’s officeor clinic

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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What You Will Pay

CommonMedical Event

Services You MayNeed Network Provider

(You will pay the least)

Out-of-NetworkProvider

(You will paythe most)

Limitations,Exceptions, &Other ImportantInformation

Preventive care/screening/immunization

No charge; deductible does not apply Not covered You may have to payfor services that aren’tpreventive. Ask yourprovider if the servicesneeded are preventive.Then check what yourplan will pay for.

Diagnostic test(x-ray, blood work)

Non-Hospital Based: No charge; deductible does notapplyPhysician & Hospital Based: Tier 1 Providers: No charge;deductible does not applyTier 2 Providers: No charge; deductible does not applyTier 3 Providers: No charge; deductible does not apply

Not covered NoneIf you have a test

Imaging (CT/PETscans, MRIs)

Non-Hospital Based: $75 copay/ procedure; deductibledoes not applyPhysician & Hospital Based: Tier 1 Providers: $75copay/ procedure; deductible does not applyTier 2 Providers: $75 copay/ procedureTier 3 Providers: $450 copay/ procedure

Not covered None

Generic drugs 30-Day Retail Tier 1: $20 copay/ prescription; deductible does not apply90-Day Mail Order Tier 1: $40 copay/ prescription; deductible does not apply30-Day Retail Tier 2: $40 copay/ prescription; deductible does not apply90-Day Mail Order Tier 2: $80 copay/ prescription; deductible does not apply

Value formulary -covers a limited list;not all drugs arecovered. Prescriptiondrug Out-of-PocketMaximum: $1,000member/ $2,000family

Preferred branddrugs

30-Day Retail Tier 3: $70 copay/ prescription; deductible does not apply90-Day Mail Order Tier 3: $210 copay/ prescription; deductible does notapply

Some generic drugs arein this tier.

If you needdrugs to treatyour illness orconditionMore informationaboutprescriptiondrug coverageis available atwww.harvardpilgrim.org/2020Value5T.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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What You Will Pay

CommonMedical Event

Services You MayNeed Network Provider

(You will pay the least)

Out-of-NetworkProvider

(You will paythe most)

Limitations,Exceptions, &Other ImportantInformation

Non-preferred branddrugs

30-Day Retail Tier 4: $125 copay/ prescription; deductible does not apply90-Day Mail Order Tier 4: $375 copay/ prescription; deductible does notapply

Same as above.

Specialty drugs 30-Day Retail Tier 4: $125 copay/ prescription; deductible does not apply90-Day Mail Order Tier 4: $375 copay/ prescription; deductible does notapply30-Day Retail Tier 5: $175 copay/ prescription; deductible does not apply90-Day Mail Order Tier 5: $525 copay/ prescription; deductible does notapply

Some drugs must beobtained through aSpecialty Pharmacy.

Facility fee (e.g.,ambulatory surgerycenter)

Tier 1 Providers: $250 copay/ visit; deductible does notapplyTier 2 Providers: $500 copay/ visitTier 3 Providers: $1,000 copay/ visit

Not coveredIf you haveoutpatientsurgery

Physician/surgeonfees

Tier 1 Providers: No charge; deductible does not applyTier 2 Providers: No chargeTier 3 Providers: No charge

Not covered

None

Emergency roomcare

$300 copay/ visit; deductible does not apply None

Emergencymedicaltransportation

No charge; deductible does not apply None

If you needimmediatemedical attention

Urgent care Convenience care clinic: Tier 1: $20 copay/ visit;deductible does not applyTier 2: $30 copay/ visit; deductible does not applyTier 3: $50 copay/ visit; deductible does not applyUrgent care center: Tier 1: $50 copay/ visit; deductibledoes not applyTier 2: $50 copay/ visit; deductible does not applyTier 3: $50 copay/ visit; deductible does not applyHospital urgent care center: Tier 1: $50 copay/ visit;deductible does not apply

Conveniencecare clinic: NotcoveredUrgent carecenter: NotcoveredHospitalurgent carecenter: Same

Services withnon-participatingproviders are onlycovered outside of theservice area.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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What You Will Pay

CommonMedical Event

Services You MayNeed Network Provider

(You will pay the least)

Out-of-NetworkProvider

(You will paythe most)

Limitations,Exceptions, &Other ImportantInformation

Tier 2: $50 copay/ visit; deductible does not applyTier 3: $50 copay/ visit; deductible does not apply

as ParticipatingProvider

Facility fee (e.g.,hospital room)

Tier 1 Providers: $250 copay/ admit; deductible does notapplyTier 2 Providers: $500 copay/ admitTier 3 Providers: $2,000 copay/ admit

Not coveredIf you have ahospital stay

Physician/surgeonfee

Tier 1 Providers: No charge; deductible does not applyTier 2 Providers: No chargeTier 3 Providers: No charge

Not covered

None

Outpatient services Tier 1 Primary Care: $20 copay/ visit; deductible doesnot apply

Not coveredIf you havemental health,behavioralhealth, orsubstance abuseneeds

Inpatient services $250 copay/ admit; deductible does not apply Not covered

None

Office visits Tier 1 Primary Care: $20 copay/ visit; deductible doesnot applyTier 2 Primary Care: $30 copay/ visit; deductible doesnot applyTier 3 Primary Care: $50 copay/ visit; deductible doesnot apply

Not covered

Childbirth/deliveryprofessional services

Tier 1 Providers: No charge; deductible does not applyTier 2 Providers: No chargeTier 3 Providers: No charge

Not covered

If you arepregnant

Childbirth/deliveryfacility services

Tier 1 Providers: $250 copay/ admit; deductible does notapplyTier 2 Providers: $500 copay/ admitTier 3 Providers: $2,000 copay/ admit

Not covered

Cost sharing does notapply for preventiveservices.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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What You Will Pay

CommonMedical Event

Services You MayNeed Network Provider

(You will pay the least)

Out-of-NetworkProvider

(You will paythe most)

Limitations,Exceptions, &Other ImportantInformation

Home health care No charge; deductible does not apply Not covered NoneRehabilitationservicesHabilitationservices

$25 copay/ visit; deductible does not apply Not covered Physical &Occupational Therapy– 60 combined visits/Plan Year

Skilled nursing care No charge; deductible does not apply Not covered – 100 days/ Plan YearDurable medicalequipment

20% coinsurance; deductible does not apply Not covered None

If you need helprecovering orhave other specialhealth needs

Hospice services No charge; deductible does not apply Not covered For inpatient see “Ifyou have a hospitalstay”.

Children’s eye exam No charge; deductible does not apply Not covered – 1 exam/ Plan YearChildren’s glasses Not covered None

If your childneeds dental oreye care

Children’s dentalcheck-up

$20 copay/ visit; deductible does not apply Not covered – 2 exams/ Plan Yearup to age 13

Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)• Long-Term (Custodial) Care• Most Cosmetic Surgery• Most Dental Care (Adult)

• Non-emergency care when traveling outsidethe U.S.

• Private-duty nursing

• Routine foot care• Services that are not Medically Necessary• Weight Loss Programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs forthese services.)

• Acupuncture - 20 visits/Plan Year• Bariatric surgery• Chiropractic Care

• Hearing Aids - $2,000/aid every 36 months,for each impaired ear up to age 22

• Infertility Treatment

• Routine eye care (Adult) - 1 exam/ Plan Year

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department ofLabor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coveragethrough the Health InsuranceMarketplace. For more information about theMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. Formore information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also providecomplete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, orassistance, contact:

HPHC Member Appeals-MemberServices DepartmentHarvard Pilgrim Health Care, Inc.1600 Crown Colony DriveQuincy, MA 02169Telephone: 1-888-333-4742Fax: 1-617-509-3085

Department of Labor’s EmployeeBenefits Security Administration1-866-444-3272www.dol.gov/ebsa/healthreform

Health Care for All30 Winter Street, Suite 1004Boston, MA 021081-800-272-4232http://www.hcfama.org/helpline

Massachusetts Division ofInsurance1000 Washington Street, Suite 810Boston, MA 02118–62001-617-521-7794

Does this plan provide Minimum Essential Coverage? YesIf you don’t haveMinimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for anexemption from the requirement that you have health coverage for that month.Does this Coverage Meet the Minimum Value Standard? YesIf your plan doesn’t meet theMinimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through theMarketplace.Language Access Services:

————— To see examples of how this plan might cover costs for a sample medical situation, see the next page. —————

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will bedifferent depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharingamounts (deductible, copayment and coinsurance) and excluded services under the plan. Use this information to compare theportion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby(9 months of in-network pre-natal care and ahospital delivery)

Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)

Mia’s Simple Fracture(in-network emergency room visit and followup care)

■ The plan’s overalldeductible

$0 ■ The plan’s overalldeductible

$0 ■ The plan’s overalldeductible

$0

■ Specialist copayment $20 ■ Specialist copayment $20 ■ Specialist copayment $20

■ Hospital (facility)copayment

$250 ■ Hospital (facility)copayment

$250 ■ Hospital (facility)copayment

$250

■ Other copayment $0 ■ Other copayment $0 ■ Other copayment $0

This EXAMPLE event includes serviceslike:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

This EXAMPLE event includes serviceslike:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

This EXAMPLE event includes serviceslike:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $12,731 Total Example Cost $7,389 Total Example Cost $1,925In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:

Cost Sharing Cost Sharing Cost SharingDeductibles $0 Deductibles $0 Deductibles $0Copayments $350 Copayments $1,260 Copayments $180Coinsurance $0 Coinsurance $0 Coinsurance $40

What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $0 Limits or exclusions $30 Limits or exclusions $0

The total Peg would payis

$350 The total Joe would pay is $1,290 The total Mia would pay is $220

The plan would be responsible for the other costs of these EXAMPLE covered services.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services