Schedule of Benefits HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS MEMBER COST SHARING

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1 Schedule of s HARVARD PILGRIM LAHEY HEALTH VALUE HMO MASSACHUSETTS ID: MD _ X Please Note: In this plan, Members 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 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 Value HMO (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 Services are covered when Medically Necessary. Subject to the exceptions listed in the section of the Handbook titled, How the Plan Works, all services must be (1) provided or arranged by your Primary Care Provider (PCP) and (2) provided by a Harvard Pilgrim Lahey Health Value HMO Plan Provider. These requirements do not apply to care needed in a Medical Emergency. In a Medical Emergency you should go to the nearest emergency facility or call 911 or other local emergency access number. A Referral from your PCP is not needed. Your emergency room Member, including your Deductible if applicable, is listed in the tables below. 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 applicable to a service or procedure for which coverage is requested. Clinical review criteria may be obtained by calling ext 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. 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, there is no Member when 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: EFFECTIVE DATE: 01/01/2016 SCHEDULE OF BENEFITS 1

2 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 You may also obtain a paper copy of the directory, free of charge, by calling Harvard Pilgrim s Member Services Department at 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. DEDUCTIBLES A Deductible is a specific annual dollar amount that is payable by the Member for Covered s received each Calendar Year before any benefits subject to the Deductible are payable by the Plan. If a family Deductible applies, it is met when any combination of Members in a covered family incur expenses for services to which the Deductible applies. Your Plan s Deductible amounts are listed in the tables below. The Plan also has limits on the Deductible amounts that apply to each tier. If you only use services intier1duringthecalendaryear, youwouldonlyberesponsibleforthetier1deductibleamount in that Calendar Year. If you only use services in Tiers 1 and 2 in a Calendar Year, you would only be responsible for the Tier 2 Deductible amount in that Calendar Year. Any Deductible amount you incur during a Calendar Year will apply to both the Tier 2 and Tier 3 Deductible amounts. The Deductible is applicable to some services covered by the Plan. You can learn about the services that require payment of a Deductible and the amounts from the tables below. Deductible amounts are incurred on the date of service. Your Plan has both an individual Deductible and a family Deductible. However, the family Deductible only applies if you have Family Coverage. Unless a family Deductible applies, you are responsible for the individual Deductible for Covered s each Calendar Year. If you have family coverage, the Deductible can be satisfied in one of two ways: a. If a Member of a covered family meets the individual Deductible, then services for that Member that are subject to that Deductible are covered by the Plan for the remainder of the Calendar Year. b. If any number of Members in a covered family collectively meet the family Deductible, then all Members of the covered family are deemed to have met the Deductible for the remainder of the Calendar Year. SCHEDULE OF BENEFITS 2

3 Any Deductible amount incurred for any Covered Service during a Calendar Year will apply toward the Deductible for that year. For example, a Member incurred a Deductible for care in a Tier 2 hospital in January. The Deductible amount incurred in January will apply toward the Deductible payable under the Plan for any Covered Service received later in the Calendar Year. This includes care in a Tier 3 hospital to which a higher Deductible applies. Once the Deductible is met, no further Deductible applies for the remainder of the Calendar Year. However, coverage by the Plan remains subject to any other Member that may apply. DEDUCTIBLE AND OTHER COST SHARING For certain services, both a Deductible and either a Copayment or Coinsurance may apply. In such cases, you must completely satisfy the Deductible before the Plan pays benefits on services subject to the Deductible. Once you have satisfied the annual Deductible, you are still responsible for any applicable Copayments or Coinsurance. COINSURANCE Coinsurance is a percentage of the cost for certain services that is payable by the Member. Please see the table below for the Coinsurance amounts that apply to your Plan. COPAYMENTS A Copayment is a fixed dollar amount that is payable by the Member for certain Covered s. Please see the table below for the Copayment amounts that apply to your Plan. Copayments are due at the time services are rendered or when billed by the provider. Different Copayments apply depending on the type of service, the tier placement of the provider, the specialty of the provider and the location of service. OUT-OF-POCKET MAXIMUM You have an Annual Out-of-Pocket Maximum of $4,000 per Member or $8,000 per family, which includes all Member except prescription drugs. General Features: Coinsurance and Copaymentsj : See Covered s below Office Visit Copayment Pediatric (up to j Office Visit Copayment Adultj : : $80 Copayment SCHEDULE OF BENEFITS 3

4 General Features: Deductiblesj : None : $500 per Member per Calendar Year $1,000 per family per Calendar Year : $1,000 per Member per Calendar Year $2,000 per family per Calendar Year Please Note: The maximum amount you will pay for a Deductible in a Calendar Year will not exceed the Tier 3 Deductible amounts. For Example, if you have satisfied your Deductible of $500 and then receive Covered s from a Tier 3 Provider that apply toward your Tier 3 Deductible, you will not be required to pay the full $1,000 Tier 3 Deductible. $500 has already been satisfied when the Tier 2 Deductible was met. Deductible Rolloverj None Out-of-Pocket Maximumj Includes all Member except charges for prescription drugs. $4,000 per Member per Calendar Year $8,000 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 Professional Services Coverage for the treatment of Autism Spectrum Disorders is provided for all of the services otherwise covered under your Plan. However, no benefit limit applies to services for the treatment of Autism Spectrum Disorders. Applied Behavior Analysis No benefit limit applies to this service. Chemotherapy and Radiation Therapyj Your Member cost sharing depends upon the type of service 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 and Other Professional Office Visits. For services by a Licensed Mental Health Professional see Mental Health Care (Including the Treatment of Substance Abuse Disorders). For services by a physical therapist or occupational therapist, see Rehabilitation Therapy - Outpatient. SCHEDULE OF BENEFITS 4

5 Dental Servicesj Emergency Dental Care Your Member will depend upon the types of services provided and the tier placement of the provider rendering services, as listed in this Schedule of s. For example, for services provided in a dentist s office, see Physician and Other Professional Office Visits. For services provided in a hospital emergency room, see Emergency Room Care. Extraction of teeth impacted in bone Preventive Dental Care for children (up to the age of 13) limited to 2 preventive dental exams per Calendar Year, only the following services are included: Cleaning Fluoride treatment Teaching plaque control X-rays Important Notice: Coverage of Dental Care is very limited. Please see your Handbook for the details of your coverage. Dialysisj Non hospital based dialysis services for Hospital based dialysis services Installation of home equipment is covered up to $300 in a Member's lifetime. 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 for SCHEDULE OF BENEFITS 5

6 Emergency Room Carej $150 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 40% Coinsurance for Inpatient Maternity Care 40% Coinsurance Inpatient Routine Nursery Care, including prophylactic medication to prevent gonorrhea Inpatient Rehabilitation Limited to 60 days per calendar year Skilled Nursing Facility Limited to 100 days per calendar year Infertility Services and Treatments (see the Handbook for details)j Consultations, Evaluations and Laboratory Tests 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 Your Member will depend upon the types of 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 and Other Professional Office Visits. 40% Coinsurance (Continued on next page) SCHEDULE OF BENEFITS 6

7 Laboratory and Radiology Services (Continued) Physician and non hospital based high $75 Copayment end radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) for Hospital based high end radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services) 20% Coinsurance 40% Coinsurance for Please Note: No Member applies to certain preventive care services. For a list of covered preventive services, please see the Preventive Services notice at: Low Protein Foodsj Limited to $5,000 per Calendar Year Maternity Care - Outpatient j Routine outpatient prenatal and postpartum care Note: Member cost sharing may apply to prenatal ultrasounds when billed as a specialized or non-routine service. See Laboratory and Radiology Services for your applicable Member. Please note: 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, for services provided by another physician or specialist, see Physician and Other Professional Office Visits for your applicable Member. Please see your Handbook for more information on maternity care. 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 Mental Health Care (Including the Treatment of Substance Abuse Disorders)j Please note: Your Plan includes the benefits required under the federal Mental Health Parity Act. (Continued on next page) SCHEDULE OF BENEFITS 7

8 Mental Health Care (Including the Treatment of Substance Abuse Disorders) (Continued) Inpatient Mental Health Services Mental health services Drug and Alcohol Rehabilitation Services Detoxification Intermediate Mental Health Care 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 Mental Health Care Services Group therapy Mental health services Individual therapy Drug and alcohol rehabilitation services Detoxification Medication management Methadone maintenance Not covered Psychological testing and neuropsychological assessment Performed by a Licensed Mental Health Professional Performed by a Neurologist or other medical specialist. Ostomy Suppliesj for $80 Copayment for 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 $80 Copayment for (Continued on next page) SCHEDULE OF BENEFITS 8

9 Physician and Other Professional Office Visits (This includes all covered Plan Providers unless otherwise listed in this Schedule of s.) (Continued) Consultations, evaluations and sickness and injury care $80 Copayment 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 Office surgical procedures Administration of allergy injections $10 Copayment for for Preventive Services and Testsj Preventive care services, including all FDA approved contraceptive devices. Under the federal health care reform law, many preventive services and tests are covered with no Member Cost Sharing. For a list of covered preventive services, please see the Preventive Services Notice on our website at: You may also get a copy of the Preventive Services Notice by calling the Member Services Department at Under federal law the list of preventive services and tests covered under this benefit may change periodically based on the recommendations of the following agencies: a. Grade A and B recommendations of the United States Preventive Services Task Force; b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and c. With respect to services for women, infants, children and adolescents, the Health Resources and Services Administration. Information on the recommendations of these agencies may be found on the web site of the U.S. Department of Health and Human Services at: Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordance with changes in the recommendations of the agencies listed above. You can find a list of the current recommendations for preventive care on Harvard Pilgrim s web site at Prosthetic Devicesj SCHEDULE OF BENEFITS 9

10 Rehabilitation Therapy - Outpatientj Cardiac Rehabilitation Pulmonary rehabilitation therapy Speech-Language and Hearing Services 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. for for for for Scopic Procedures - Outpatient Diagnostic and Therapeutic j Colonoscopy, endoscopy and Your Member will depend upon where the sigmoidoscopy 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. Please Note: No Member applies to certain preventive care services, including screening colonoscopies. For a list of covered preventive services, please see the Preventive Services notice at: Spinal Manipulative Therapy (including care by a chiropractor)j Limited to 12 visits per Calendar Year Surgery Outpatient j 20% Coinsurance 40% Coinsurance for Urgent Care Servicesj Convenience care clinic Urgent care clinic (including hospital urgent care clinic) for $80 Copayment for (Continued on next page) SCHEDULE OF BENEFITS 10

11 Urgent Care Services (Continued) 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. Vision Servicesj Routine eye examinations -limited to 1 exam per Calendar Year $80 Copayment Vision hardware for special conditions (see the Handbook for details) Voluntary Sterilizationj Voluntary Termination of Pregnancyj 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) for for 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 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 SCHEDULE OF BENEFITS 11