April 16, 2023

Harvard Pilgrim HMO Schedule of Benefits

The harvard pilgrim hmo schedule of benefits provides details about your health care coverage. It includes the Covered Benefits, Copayments, Coinsurance and Deductible amounts that you must pay for medically necessary services billed by your Plan Provider.

Definitions and Exclusions

Drug Coveragej The Plan covers any drug that has been prescribed by your Primary Care Physician (PCP), except (a) drugs for cosmetic purposes; (b) syringes and needles or other devices used in delivering a drug to your body; and (c) drugs for which the prescription has been previously filled by an outpatient pharmacy. You may have a prescription drug rider which will list your Member Cost Sharing for medications you receive at an outpatient pharmacy.

Vision and Hearingj The Plan covers eyeglasses, contact lenses and fittings, as well as hearing aids, up to the Benefit Limit listed in your Schedule of Benefits. You must meet the eligibility requirements for this benefit in order to qualify.

Family Coveragej The Plan covers your family members who meet the eligibility requirements in this Handbook and the Schedule of Benefits. This includes your spouse, domestic partners and dependent children.

Custodial Carej * Recovery programs including rest or domiciliary care, sober houses, transitional support services and therapeutic communities. All institutional charges over the semi-private room rate, except when a private room is Medically Necessary.

Pain Managementj * Medical and surgical pain management for non-cancer conditions.

Postpartum Carej * Routine prenatal and postpartum care when you are traveling outside of the Service Area, as long as you do not have a high risk pregnancy or are receiving care in a physician's office.


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