CODE: CL-SMF ScheduleofBenefits

ID: MD0000003094CODE: CL-SMF

Schedule of BenefitsHPHC Insurance Company, Inc.HOSPITAL PREFER℠ — LP BEST BUY PPONEW HAMPSHIRE

Coverage under this Plan is under the jurisdiction of the New Hampshire Insurance Commissioner.

IMPORTANT INFORMATION: This policy reflects the known requirements for complianceunder The Affordable Care Act as passed on March 23, 2010. As additional guidanceis forthcoming from the US Department of Health and Human Services, and the NewHampshire Insurance Department, those changes will be incorporated into your healthinsurance policy.

This Schedule of Benefits summarizes your Benefits under the HPHC Insurance Company PPO (thePlan) and states the Member Cost Sharing amounts you must pay for Covered Benefits. However,it is only a summary of your benefits. Please see your Benefit Handbook and Prescription DrugBrochure (if you have the Plan’s outpatient pharmacy coverage) for detailed information on thebenefits covered by the Plan and the terms and conditions of coverage.

There are two levels of coverage: In-Network and Out-of-Network.• In-Network coverage applies when you use a Plan Provider for Covered Benefits. When using

Plan Providers, coverage is based on the contracted rate between HPHC and the Provider.

• Out-of-Network coverage applies when you use a Non-Plan Provider for Covered Benefits.When using Non-Plan Providers, the Plan pays only a percentage of the cost of the care youreceive up to the Usual, Customary and Reasonable Charge for the service. In most cases, thiswill be higher than the HPHC contracted rate. If a Non-Plan Provider charges any amount inexcess of the Usual, Customary and Reasonable Charge, you are responsible for the excessamount. Please refer to Section I.F. (“Member Cost Sharing”) in your Benefit Handbook foradditional information about Out-of-Network charges in excess of the Usual, Customaryand Reasonable Charge.

You always have coverage for care in a Medical Emergency. In a Medical Emergency, you shouldgo to the nearest emergency facility or call 911 or other local emergency number. Your emergencyroom Member Cost Sharing is listed below under the heading “Emergency Room Care.”

Member Responsibility for Notification and Prior Approval

Members must contact HPHC for coverage of a number of services. These are listed below.

Mental Health and Drug and Alcohol Rehabilitation Services. Prior Approval mustbe obtained before receiving certain mental health and drug and alcohol rehabilitationservices from Non-Plan Providers. For a list of such services, please refer to our internetsite, www.harvardpilgrim.org. You may also contact the Member Services Department at1-888-333-4742. To obtain Prior Approval for mental health and drug and alcohol rehabilitationservices, please call the Behavioral Health Access Center at 1-888-777-4742.

Medical Services. Members are required to notify HPHC before the start of any plannedinpatient admission to a Non-Plan medical facility. Members are also required to obtain PriorApproval from HPHC for certain services. Before you receive services from a Non-Plan Provider,please refer to our Internet site, www.harvardpilgrim.org, or contact the Member ServicesDepartment at 1-888-333-4742 for a list of Out-of-Network services that require Prior Approval.EFFECTIVE DATE: 06/01/2013

FORM #1503 SCHEDULE OF BENEFITS | 1

http://www.harvardpilgrim.org


HOSPITAL PREFER℠℠℠ — LP BEST BUY PPO - NEW HAMPSHIRE

If you do not provide notification or obtain Prior Approval when required, you will be responsiblefor paying the Penalty amount stated in this Schedule of Benefits in addition to any applicableMember Cost Sharing. No coverage will be provided if HPHC determines that the service is notMedically Necessary. In that case, you will be responsible for the entire cost of the service.

Emergency Care. You do not need to contact HPHC before receiving care in a MedicalEmergency. In the event of an emergency hospital admission to a Non-Plan Provider, you mustnotify HPHC within 48 hours of the admission, unless notification is not possible because of yourcondition. If notice is given to HPHC by an attending emergency physician, no further notificationis required. However, if notification is not received when the Member's condition permits it, theMember is responsible for the Penalty amount stated in this Schedule of Benefits. Please call1-800-708-4414 to notify us of an emergency admission to a Non-Plan facility.

Clinical Review Criteria

We use clinical review criteria to evaluate whether certain services or procedures are MedicallyNecessary for a Member’s care. Members or their practitioners may obtain a copy of our clinicalreview criteria applicable to a service or procedure for which coverage is requested. Clinicalreview criteria may be obtained by calling 1-888-888-4742 ext. 38723.

Outpatient Surgery, Laboratory and Scopic Procedures — Outpatient Diagnostic andTherapeutic Services

HPHC has designated certain In-Network outpatient surgical centers and laboratory facilities asSelect LP Providers. These providers were chosen based on their cost efficiency and render thesame quality of service at a lower cost than other providers in the network. When you receiveservices from a Select LP Provider, your Member out-of-pocket costs will be less than if youreceived the same services from providers that are not Select LP Providers. The tables set forthbelow list the Member Cost Sharing for each type of Select LP Provider.

The Plan’s Provider Directory lists all Plan Providers including those providers that are Select LPProviders. You can access the Provider Directory at www.harvardpilgrim.org. You may alsoobtain a paper copy of the directory, free of charge by calling the Member Services Departmentat 1-888-333-4742.

HPHC establishes its list of Select LP Providers in January of each year. HPHC will not removeproviders from its Select LP Provider List during January through the following December of eachyear. HPHC may also add Select LP Providers to its list any time during the year.

Your Covered Benefits are administered on a Plan Year basis. Your Plan Year begins on yourEmployer’s Anniversary Date. Please see your Benefit Handbook for more details. If you do notknow your Employer’s Anniversary Date, please contact your Employer’s benefits office or call theMember Services Department at 1-888-333-4742.

MEMBER COST SHARING

Members are required to share the cost of the Covered Benefits provided under the Plan. Thissection describes the payments for which you are responsible, called Member Cost Sharing.Different Member Cost Sharing applies to In-Network and Out-of-Network care. The tables, setforth below, show the specific Member Cost Sharing amounts for the different services covered bythe Plan.

PREVENTIVE SERVICES

No Member Cost Sharing applies to certain preventive services received from Plan Poviders.These services are summarized below and further described in the tables later in this Scheduleof Benefits:




– Annual preventive gynecological examinations– Immunizations– Specified Preventive services and tests– Routine prenatal and routine postpartum care– Routine well physical examinations (including well child care, vision and auditory screening

for children, nutrition counseling and health education)Please Note: Member Cost Sharing applies to all preventive care services received from Non-PlanProviders (Out-of-Network Providers). You must use Plan Providers (In-Network Providers) forcoverage of the listed preventive care services with no Member Cost Sharing.

TIERED HOSPITALS — IN-NETWORK

In-Network Acute Hospitals are placed into one of three benefit levels or “tiers” based on nationalmeasures of cost efficiency and relative quality. Member Cost Sharing, including Deductibleamounts, for these hospitals depends upon the tier in which the hospital is placed. Tier 1 is thelowest cost tier. Tier 2 is the medium cost tier. Tier 3 is the highest cost tier. Please see your BenefitHandbook for more information on how hospitals are tiered under the Plan.

You can lower your out-of-pocket cost by selecting In-Network hospitals in the lower cost tiers.The tables set forth below list the Member Cost Sharing for each type of tiered service. TheHospital Prefer Provider Directory lists all Plan Providers and, in the case of Acute Hospitals,their tier. You can access the Hospital Prefer Provider Directory at www.harvardpilgrim.org. Youmay also obtain a paper copy of the directory, free of charge, by calling our Member ServicesDepartment at 1–888–333–4742.

Please note: When you choose a provider, it is important to consider the tier of the hospitalthat your physician uses. For example, a physician may admit patients to either a Tier 1, Tier2 or Tier 3 hospital.

DEDUCTIBLESA Deductible is a dollar amount a Member must pay each Plan Year before any benefits subject tothe Deductible are payable by the Plan. Any eligible expenses you incur toward the Deductible ina Plan Year apply to both your Plan’s In-Network and Out-of-Network Deductibles.

Your Plan has an individual Deductible. If you have family coverage you also have a separatefamily Deductible. If a family Deductible applies, it is met when any combination of Membersin a covered family incur expenses for services to which the Deductible applies. Your Plan’sDeductibles are listed in the tables below.

For certain services, both a Deductible and a Copayment or Coinsurance may apply. Once youhave satisfied the annual Deductible, you are still responsible for any applicable Copayments orCoinsurance required by your Plan.

For In-Network Services, your Plan may have one or more of the following Deductibles. Pleasereview the tables below to determine the specific Deductibles that apply to your Plan and theamounts payable by you.

General Deductible. Your Plan has a General Deductible. The General Deductible applies tomost In-Network services covered by the Plan.

Any amounts you incur toward the General Deductible also apply to the Hospital Deductible,which is described below. For example, if you incur $500 in General Deductible expenses foroutpatient care early in a Plan Year, that amount would also be applied toward the HospitalDeductible for the Plan Year. The amount of your Hospital Deductible would be reduced by the$500 you incurred toward the General Deductible.



Hospital Deductible. Your Plan has a Hospital Deductible. The Hospital Deductible applies tomost In-Network services you receive at (1) an Acute Hospital, (2) a facility affiliated with an AcuteHospital, or (3) a free standing surgical center. Hospital services include inpatient stays; surgery;outpatient procedures and day surgery; and laboratory and radiology services. The tables belowidentify the services that require payment of the Hospital Deductible.

An Acute Hospital is any hospital that primarily provides treatment of physical illnesses or injuries,including maternity care or the care of newborn infants. An Acute Hospital does not include ahospital that primarily provides mental health care, such as a psychiatric hospital, or a hospitalthat primarily provides inpatient rehabilitation. Services received from an affiliated facility ofan Acute Hospital, such as a free standing outpatient center, that are billed through the AcuteHospital will be considered Acute Hospital services.

Each Acute Hospital that is a Plan Provider is assigned a “Tier” by HPHC. The Tier of the hospitaldetermines the amount of the Hospital Deductible at each facility. A Tier 1 hospital will have thelowest Hospital Deductible. A Tier 2 hospital will have a deductible between Tier 1 and Tier 3. ATier 3 hospital will have the highest Deductible. The Acute Hospitals that are Plan Providers arelisted in the Plan’s Provider Directory with the Tier that applies to each hospital.

When you use Acute Hospital services, the amount of your Hospital Deductible depends on theTiers of the hospitals used. If you only use services of a Tier 1 hospital in a Plan Year, you will onlybe responsible for the Tier 1 Hospital Deductible for that Plan Year. Similarly, services you receiveat a Tier 2 or Tier 3 hospital require that you meet the corresponding Tier 2 or Tier 3 HospitalDeductible for that Plan Year.

There are certain services that always require payment of the Tier 1 Hospital Deductible. Theseinclude inpatient mental health care or inpatient rehabilitation care at Acute Hospitals that arePlan Providers. Those services will only require payment of the Tier 1 Hospital Deductible, even ifyou are hospitalized at a Tier 2 or Tier 3 hospital. The tables below identify all of the servicesthat are considered Tier 1 services.

For Out-of-Network Services, the Plan has a separate Deductible that applies to Out-of-NetworkServices. The Out-of Network Deductible is generally higher than the Tier 3 In-Network HospitalDeductible. Please see the tables below for your Out-of-Network Deductible.

How Your General, Hospital and Out-of-Network Deductibles Work Together

Your General Deductible, Hospital Deductible and Out-of-Network Deductible apply to each otherduring the Plan Year. This is illustrated in the following example:

Assume that Tim is a Member of a Plan that has the following In-Network Deductibles:

General Deductible: $500

Hospital Deductibles: Tier 1, $500; Tier 2, $1,000; Tier 3, $1,500.

Also assume that Tim’s Plan has a $3,000 Out-of-Network Deductible.

If Tim incurred $900 in Deductible expenses at an In-Network Tier 2 hospital early in a PlanYear, that amount would be applied toward both the In-Network and Out-of-NetworkDeductibles for that Plan Year.

For In-Network Coverage, Tim would have both met his In-Network General Deductible andIn-Network Tier 1 Hospital Deductible for that Plan Year. Tim would have also reduced hisremaining In-Network Tier 2 and Tier 3 Hospital Deductible amounts by $900 for that PlanYear. The remaining In-Network Tier 2 Hospital Deductible amount would be $100 and theremaining Tier 3 Hospital Deductible amount would be $700 for that Plan Year.



For Out-of- Network Coverage Tim would have reduced his remaining Out-of-NetworkDeductible by $900. The remaining Out-of-Network Deductible would be $2,100 for thatPlan Year.

If Tim receives further services during the Plan Year to which a deductible applies, thosecharges would be applied toward any unmet Deductible amounts for the Plan Year.

Deductible amounts are incurred on the date of service. Once you meet the Deductible thatapplies to an In-Network or the Out-of-Network Deductible, no further Deductible is payablefor that category of benefits for the remainder of the Plan Year. However, coverage by the Planremains subject to any Copayments or Coinsurance that may apply.

Other Deductibles You Must Pay

The following Deductibles are separate from the Deductibles listed above and are calculatedindependently from any of the other Deductible amounts.

In-Network Durable Medical Equipment and Prosthetic Device Deductible. Your Planmay have a separate In-Network Deductible that applies toward coverage for Durable MedicalEquipment and Prosthetic Devices. If that deductible applies, it is completely separate from theIn-Network General Deductible and the In-Network Hospital Deductible described above. Pleasesee the tables below for further information on the Member Cost Sharing for In-Network DurableMedical Equipment and Prosthetic Devices.

Outpatient Prescription Drug Deductible. If you are covered by the Plan’s optional coveragefor outpatient prescription drugs, you may have a separate deductible under that coverage. Ifthe Outpatient Prescription Drug Deductible applies, it is completely separate from the otherDeductibles described above. Please refer to your Prescription Drug Brochure for specificinformation on your Prescription Drug Deductible, if any.

COINSURANCE

Coinsurance is a percentage of the cost for certain covered services that is payable by the Member.Please see the tables 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 coveredservices. A Copayment is due at the time services are rendered or when billed by the provider.Different Copayments apply depending on the type of service, the specialty of the providerand the location of service.

For In-Network Services, your Plan has two types of Copayments that apply to your Plan. Alower Copayment, known as the “Primary Care Copayment,” applies to some outpatient services,including most primary care, obstetrical care, gynecological care, and mental health care and drugand alcohol rehabilitation services. Most outpatient specialty care requires payment of a higherCopayment, known as the “Specialty and Hospital Based Care Copayment.” Your Copayments arelisted in the tables below.

With the exception of the preventive services in the table below, which are neversubject to Member Cost Sharing when received from Plan Providers, the followingCopayments apply to the outpatient services covered by your Plan:

The Primary Care Copayment

The Primary Care Copayment applies to the following In-Network outpatient services:• Applied Behavior Analysis

• Mental health and drug and alcohol rehabilitation services



• Audiology services• Vision and auditory screening for children• Nutritional counseling• Allergy injections

In addition to the services listed above, the Primary Care Copayment applies to covered outpatientprofessional services, other than services received at a professional office operated by a hospital,from the following types of providers:

• All Primary Care Providers. The term “Primary Care Provider” (PCP) includes physicians oradvanced registered nurse practitioners in the following specialties: Internal medicine, FamilyPractice, General Practice and Pediatrics

• Obstetricians and Gynecologists• Nurse practitioners who bill independently• Certified midwives• Chiropractors

The Specialty and Hospital Based Care Copayment

The Specialty and Hospital Based Care Copayment applies to the following In-Network outpatientservices:

• Any covered service or provider that is not listed above under Primary Care Copayment, or• Any service provided in a hospital operated doctor’s office, except the specific services listed

under the Primary Care Copayment above.If a provider is categorized at both Copayment levels, the Primary Care Copayment applies. Forexample, if a provider is both a PCP and a cardiologist, you will be responsible for the PrimaryCare Copayment.

General Cost Sharing Features: Member Cost SharingIn—Network Copaymentsj

Primary Care Copayment: Your Plan has a $25 Copaymentper visitSpecialty and Hospital Based Care Copayment: Your Planhas a $50 Copayment per visit

Coinsurance and Other CopaymentsjSee Covered Benefits below.

In-Network DeductiblejThe following Deductibles apply to allservices except where specifically notedin the benefit table below.

General Deductible:$2,000 per Member per Plan Year$6,000 per family per Plan YearTier 1 Hospital Deductible:$2,000 per Member per Plan Year$6,000 per family per Plan YearTier 2 Hospital Deductible:$3,000 per Member per Plan Year$9,000 per family per Plan YearTier 3 Hospital Deductible:$4,000 per Member per Plan Year$12,000 per family per Plan Year



General Cost Sharing Features: Member Cost Sharing

Out-of-Network DeductiblejThe following Deductibles apply to allservices except where specifically notedin the benefit table below.

$4,000 per Member per Plan Year$12,000 per family per Plan Year

In-Network Durable Medical Equipment and Prosthetic Devices Deductiblej$100 per Member per Plan Year

Out-of-Pocket Maximumj– Includes all In-Network and

Out-of-Network Member CostSharing except charges foroutpatient prescription drugs.Any charges above the Usual,Customary and ReasonableCharge and any penalty for failureto receive Prior Approval whenusing Non-Plan Providers donot apply to the Out-of-PocketMaximum.

$10,000 per Member per Plan Year$36,000 per family per Plan Year

Out-of-Network Penalty Payment for failure to obtain Prior ApprovaljYou must notify HPHC in advance of any planned inpatient admission to a Non-Plan Medical Facility.You are also required to obtain Prior Approval from HPHC before receiving certain services from aNon-Plan Provider. If you do not provide notification or get Prior Approval for these services, you areresponsible for 50% of the benefit that would have otherwise been payable or $500 which ever is less.This Penalty charge is in addition to any Member Cost Sharing amounts and does not count toward theDeductible or Out-of-Pocket Maximum. Please see section I.G. NOTIFICATION AND PRIOR APPROVAL inyour handbook for more information.Deductible RolloverjNone

Benefit In-Network Plan ProvidersMember Cost Sharing

Out-of-Network Non-PlanProviders Member CostSharing

Ambulance Transportj– Emergency ambulance transport In-Network General

Deductible, then no chargeSame as In-Network

– Non-emergency ambulancetransport

In-Network GeneralDeductible, then no charge

Out-of-Network Deductible,then 20% Coinsurance





Autism Spectrum Disorders Treatment j– Applied behavior analysis – limited

to $36,000 per Plan Year forMembers through the age of 12and $27,000 per Plan Year forMembers age 13 to 21

Primary Care Copayment: $25Copayment per visit


– All other benefits are covered asstated in this Schedule of Benefits

Your Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For services providedby a speech therapist, physicaltherapist and occupationaltherapist see "RehabilitationTherapy – Outpatient.”


Bariatric SurgeryjYour Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Chemotherapy and Radiation Therapy — Outpatientj– Chemotherapy– Radiation therapy

In-Network Deductible, thenno charge


Chiropractic CarejLimited to 12 visits per Plan Year Primary Care Copayment: $25

Copayment per visitOut-of-Network Deductible,then 20% Coinsurance





Clinical TrialsjYour Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Dental ServicesjImportant Notice: Coverage of Dental Care is very limited. Please see your Benefit Handbook for thedetails of your coverage.

– Accidental injury dental care Your Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided in adentist’s office, see “Physicianand Other Professional OfficeVisits.” For services providedin a hospital emergencyroom, see “Emergency RoomCare.”


– Outpatient Surgery Expenses forDental Care

Your Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For day surgery, see“Surgery – Outpatient.”






Diabetes Services and Suppliesj– Self management and

training/diabetic eyeexaminations/foot care

Primary Care Copayment: $25Copayment per visitSpecialty and HospitalBased Care Copayment: $50Copayment per visit


– Diabetes equipment and supplies In-Network Durable MedicalEquipment and ProstheticDevices Deductible, then 20%CoinsuranceIn-Network Member CostSharing does not apply toblood glucose monitors orinsulin pumps (includingsupplies) and infusion devices


– Pharmacy supplies Subject to the applicablepharmacy Member CostSharing listed on your IDCard.

Subject to the applicablepharmacy Member CostSharing listed on your IDCard.

If your Plan does not include coverage for outpatient prescription drugs, then coverage is subject to thelower of the pharmacy’s retail price or a Copayment of $5 for Tier 1 drugs or supplies, $10 for Tier 2 drugsor supplies, and $25 for Tier 3 drugs or supplies.For information on the drug tiers, please visit our website at www.harvardpilgrim.org/members andselect "pharmacy/drug tier look up" or contact the Member Services Department at 1-888-333-4742.Dialysisj

– Dialysis services at a physician’soffice or non-hospital affiliatedfacility



– Dialysis services at an AcuteHospital or hospital affiliatedfacility

See “Hospital – InpatientServices.” for your MemberCost Sharing.


– Installation of home equipment iscovered up to $300 in a Member'slifetime.

No charge Out-of-Network Deductible,then 20% Coinsurance

Durable Medical Equipment jIn-Network Durable MedicalEquipment and ProstheticDevices Deductible, then 20%CoinsuranceMember Cost Sharing doesnot apply to the following:

– Respiratory equipment– Oxygen and oxygen

equipment


Early Interventionj- limited to $3,200 per Member per PlanYear, up to $9,600 per lifetime

Primary Care Copayment :$25 Copayment per visit






Emergency AdmissionjThis benefit only applies to admissions toAcute Hospitals when: (1) the admissiontakes place during, or immediatelyfollowing, a Medical Emergency and (2)the admission is directly from the AcuteHospital’s emergency room. Please seethe benefit for “Hospital – InpatientServices” for other Acute HospitalServices.

In-Network Tier 1 HospitalDeductible, then no charge

Same as in-Network

Emergency Room Carej– Facility charges In-Network Tier 1 Hospital

Deductible, then $250Copayment per visitThis Copayment is waivedif admitted to the hospitaldirectly from the emergencyroom.

Same as In-Network

– Physician charges No charge Same as In-Network

Family Planning ServicesjPrimary Care Copayment: $25Copayment per visitSpecialty and HospitalBased Care Copayment: $50Copayment per visit


Hearing Aids jLimited to

– $1,500 per hearing aid every 60months, for each hearing impairedear


Home Health CarejNo charge Out-of-Network Deductible,

then 20% CoinsuranceHospice Servicesj

No charge for outpatientservices.For inpatient hospital care,see “Hospital – InpatientServices.”


Hospital – Inpatient Services in an Acute HospitaljTier 1 Hospitals:In-Network Tier 1 HospitalDeductible, then no chargeTier 2 Hospitals:In-Network Tier 2 HospitalDeductible, then no chargeTier 3 Hospitals:In-Network Tier 3 HospitalDeductible, then no charge






House CallsjPrimary Care Copayment: $25Copayment per visitSpecialty and HospitalBased Care Copayment: $50Copayment per visit


Human Organ Transplant ServicesjYour Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Infertility Services [and Treatment] [(see the Benefit Handbook for details)]jThe Plan covers the following diagnosticservices for infertility:

– Consultation– Evaluation– Laboratory tests

Please Note: The Plan does not coverinfertility treatment.

Your Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.


Laboratory and Radiology Servicesj– Laboratory services at a physician’s

office or non-hospital affiliatedfacility

Select LP ProvidersNo chargeOther Plan ProvidersIn-Network GeneralDeductible, then no charge


– Laboratory services at an AcuteHospital or hospital affiliatedfacility

Tier 1 Hospitals:In-Network Tier 1 HospitalDeductible, then no chargeTier 2 Hospitals:In-Network Tier 2 HospitalDeductible, then no chargeTier 3 Hospitals:In-Network Tier 3 HospitalDeductible, then no charge


– X-rays at a physician’s office ornon-hospital affiliated facility







Laboratory and Radiology Services (Continued)– X-rays at an Acute Hospital or

hospital affiliated facilityTier 1 Hospitals:In-Network Tier 1 HospitalDeductible, then no chargeTier 2 Hospitals:In-Network Tier 2 HospitalDeductible, then no chargeTier 3 Hospitals:In-Network Tier 3 HospitalDeductible, then no charge


– High end radiology (CT scans, PETscans, MRI and MRA, and nuclearmedicine services) at a physician’soffice or non-hospital affiliatedfacility



– High end radiology (CT scans, PETscans, MRI and MRA, and nuclearmedicine services) at an AcuteHospital or hospital affiliatedfacility



No Member Cost Sharing applies to certain preventive careservices. See "Preventive Services and Tests," below.

Low Protein FoodsjLimited to $1,800 per Member per PlanYear


Maternity Carej– Routine outpatient prenatal and

postpartum careNo charge Out-of-Network Deductible,

then 20% Coinsurance– Preventive services and screenings

including: counseling aboutalcohol and tobacco use, servicesto promote breastfeeding, routineurinalysis and screenings forthe following: asymptomaticbacteriuria; hepatitis B infection;HIV and screenings for STDs(chlamydia, gonorrhea andsyphilis); iron deficiency anemia;and Rh (D) incompatibility.


Please see “Preventive Services and Tests,” below, for additional services and tests covered with noMember Cost Sharing.Please note: Routine prenatal and postpartum care is usually received and billed from the sameProvider as a single or bundled service. Different Member Cost Sharing may apply to any specialized ornon-routine service that is billed separately from your routine outpatient prenatal and postpartumcare. For example, for services provided by another physician or specialist, see “Physician and Other





Maternity Care (Continued)Professional Office Visits” for your applicable Member Cost Sharing. Please see your Benefit Handbookfor more information on maternity care.

– Routine nursery care for thenewborn, including prophylacticmedication to prevent gonorrheaand screenings for the following:hearing loss; congenitalhypothyroidism; phenylketonuria(PKU); and sickle cell disease.


– Acute Hospital inpatient services Tier 1 Hospitals:In-Network Tier 1 HospitalDeductible, then no chargeTier 2 Hospitals:In-Network Tier 2 HospitalDeductible, then no chargeTier 3 Hospitals:In-Network Tier 3 HospitalDeductible, then no charge


Medical FormulasjNo charge Out-of-Network Deductible,

then 20% CoinsuranceMental Health and Drug and Alcohol Rehabilitation ServicesjInpatient Services

– Mental health services– Drug and alcohol rehabilitation

services– Detoxification services

No charge 20% Coinsurance

Partial Hospitalization Services– Partial hospitalization services

No charge 20% Coinsurance

Outpatient Services– Mental health services

Individual therapy: PrimaryCare Copayment: $25Copayment per visitGroup therapy: $10Copayment per visit

20% Coinsurance

– Drug and alcohol rehabilitationservices

Individual therapy: PrimaryCare Copayment: $25Copayment per visitGroup therapy: $10Copayment per visit

20% Coinsurance

– Detoxification services Primary Care Copayment: $25Copayment per visit

20% Coinsurance

– Medication management Primary Care Copayment: $25Copayment per visit

20% Coinsurance

– Psychological testing andneuropsychological assessment

– Performed by a psychiatrist or otherlicensed mental health professional

Primary Care Copayment: $25Copayment per visit






Mental Health and Drug and Alcohol Rehabilitation Services (Continued)– Performed by a neurologist or

other medical specialistSee the benefit for"Treatments and Procedures"under "Physicians and otherProfessional Office Visits."


Ostomy SuppliesjIn-Network Durable MedicalEquipment and ProstheticDevices Deductible, then 20%Coinsurance


Physician and Other Professional Office Visits (This includes all covered Providers unless otherwise statedin this Schedule of Benefits)jRoutine examinations for preventivecare. This includes:

– Annual gynecologicalexaminations, school, camp,sports and premarital examinations

– Health education


(No Member Cost Sharing applies to certain preventive careservices. See “Preventive Services and Tests,” below.)

Consultations, evaluations and sicknessand injury careExaminations and Consultations

This includes but is not limited to:– Medication management– Nutritional counseling– Routine hearing examinations and

tests



Treatment and Procedures including butnot limited to:

– Administration of injections– Allergy treatments– Casting, suturing and the

application of dressings– Pregnancy testing– Genetic counseling– Neurological testing– Office surgical procedures– Non-routine foot care



– Administration of allergyinjections

$5 Copayment per visit Out-of-Network Deductible,then 20% Coinsurance





Preventive Services and TestsjLimited to the following selectpreventive laboratory and pathologytests and screenings as defined byfederal law:

– Abdominal aortic aneurysmscreening (for males 65-75 onetime only, if ever smoked)

– Alcohol misuse screening andcounseling (primary care visitsonly)

– Aspirin for the prevention of heartdisease (primary care counselingonly)


– Autism screening (for children at18 and 24 months of age – primarycare visits only)

– Behavioral assessments(developmental surveillance,for children of all ages – primarycare visits only)

– Blood pressure screening– Breast cancer chemoprevention

counseling (only for women athigh risk for Breast Cancer andlow risk for adverse effects ofchemoprevention)

– Breast cancer screening, includingmammograms and counseling forgenetic susceptibility screening

– Cervical cancer screening,including pap smears

– Cholesterol screening (for adultsonly)

– Colorectal cancer screening,including colonoscopy,sigmoidoscopy and fecal occultblood test

– Dental caries prevention - oralfluoride (for children to age 5only)

Note: Coverage for fluoride is onlyprovided if your Plan includes outpatientpharmacy coverage.

– Depression screening (primarycare visits only)

– Diabetes screenings


– Diet counseling– Dyslipidemia screening (for

children at high risk for higherlipid levels)






Preventive Services and Tests (Continued)– Folic acid supplements (women

planning or capable of pregnancyonly)

Note: Coverage for folic acid is onlyprovided if your Plan includes outpatientpharmacy coverage.

– Hemoglobin A1c– Hepatitis B testing– HIV screening– Immunizations, including flu

shots (for children and adults asappropriate)

– Iron deficiency prevention(primary care counseling forchildren age 6 to 12 months only)

– Lead screening (for children atrisk)

– Microalbuminuria test– Obesity screening– Osteoporosis screening (to begin

at age 60 for women at increasedrisk)

– Ovarian cancer susceptibilityscreening

– Sexually transmitted diseases -screenings and counseling

– Tobacco use counseling (primarycare visits only)

– Total cholesterol tests– Tuberculosis skin testing– Vision screening (children to age

5 only)Please see the Maternity Care benefitfor additional services and tests coveredwith no Member Cost Sharing.


Under federal law the list of preventive services and tests covered under this benefit may changeperiodically 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 forDisease Control and Prevention; andc. With respect to services for woman, infants, children and adolescents, the Health Resources andServices Administration.Information on the recommendations of these agencies may be foundon the web site of the US Department of Health and Human Services at:http://www.healthcare.gov/center/regulations/prevention/recommendations.html.Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordancewith changes in the recommendations of the agencies listed above. [You can find a list of the currentrecommendations for preventive care on Harvard Pilgrim’s web site at www.harvardpilgrim.org.]


http://www.healthcare.gov/center/regulations/prevention/recommendations.html





Prosthetic DevicesjIn-Network Durable MedicalEquipment and ProstheticDevices Deductible, then 20%Coinsurance


Reconstructive SurgeryjYour Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Rehabilitation - Inpatient CarejLimited to

– 100 days per Plan Year– Day limits combined with Skilled

Nursing Facility Care



Rehabilitation Therapy - OutpatientjCardiac rehabilitationPulmonary rehabilitation therapy



Occupational therapy - limited to– 20 visits per Plan Year

Physical therapy - limited to– 20 visits per Plan Year

Speech therapy - limited to– 20 visits per Plan Year

Specialty and HospitalBased Care Copayment: $50Copayment per visit


Scopic Procedures - Outpatient Diagnostic and Therapeuticj– Colonoscopy, endoscopy and

sigmoidoscopy at a non-hospitalaffiliated facility

Select LP Providers$75 Copayment perprocedureOther Plan ProvidersIn-Network GeneralDeductible, then no charge


– Colonoscopy, endoscopy andsigmoidoscopy at an AcuteHospital or hospital affiliatedfacility

Tier 1 Hospitals:In-Network Tier 1 HospitalDeductible, then no chargeTier 2 Hospitals:In-Network Tier 2 HospitalDeductible, then no chargeTier 3 Hospitals:






Scopic Procedures - Outpatient Diagnostic and Therapeutic (Continued)

In-Network Tier 3 HospitalDeductible, then no charge

Skilled Nursing Facility CarejLimited to

– 100 days per Plan Year– Day limits combined with

Rehabilitation Hospital Care



Surgery – Outpatientj– Surgery at a non-hospital affiliated

facilitySelect LP Providers$75 Copayment per visitOther Plan ProvidersIn-Network Tier 1 HospitalDeductible, then no charge


– Surgery at an Acute Hospital orhospital affiliated facility



TelemedicinejYour Member Cost Sharingwill depend upon the typesof services provided, and theprovider rendering servicesas listed in this Scheduleof Benefits. For example,for services provided by aphysician, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Temporomandibular Joint Dysfunction Services (medical treatment only)jYour Member Cost Sharingwill depend upon the typesof services provided and theprovider rendering services,as listed in this Scheduleof Benefits. For example,for a service provided in anoutpatient surgical center,see “Surgery– Outpatient.”For services provided by aphysician, see “Physician andOther Professional Office






Temporomandibular Joint Dysfunction Services (medical treatment only) (Continued)

Visits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”

Urgent Care Center ServicesjIn-Network Tier 1 HospitalDeductible, then $75Copayment per visit


Vision Servicesj– Routine eye examinations -limited

to 1 per Plan YearPrimary Care Copayment: $25Copayment per visit


– Vision hardware for specialconditions (see the BenefitHandbook for details)


Voluntary SterilizationjYour Member Cost Sharingwill depend upon wherethe service is provided andthe provider renderingservices, as listed in thisSchedule of Benefits. Forexample, for a serviceprovided in an outpatientsurgical center, see “Surgery–Outpatient.” For servicesprovided in a physician’soffice, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”


Voluntary Termination of PregnancyjYour Member Cost Sharingwill depend upon wherethe service is provided andthe provider renderingservices, as listed in thisSchedule of Benefits. Forexample, for a serviceprovided in an outpatientsurgical center, see “Surgery–Outpatient.” For servicesprovided in a physician’soffice, see “Physician andOther Professional OfficeVisits.” For inpatient hospitalcare, see “Hospital – InpatientServices.”






Wigs and Scalp Hair Prostheses as required by lawjIn-Network Durable MedicalEquipment and ProstheticDevices Deductible, then 20%Coinsurance



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CODE: CL-SMF ScheduleofBenefits

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