1 Your Deductible: $500 per member $1000 per family Financial - - PowerPoint PPT Presentation

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Your Deductible: $500 per member $1000 per family

• Financial responsibility before Harvard Pilgrim begins to pay

claims on your behalf

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Examples:

• You visit your PCP for your routine annual physical

Service Provided Provider Charge Allowed Amount Deductible Applied What you would pay at a Tier 1 provider or hospital What you would pay at a Tier 2 provider or hospital What you would pay at a Tier 3 provider or hospital Annual Wellness Visit $325.00 $200.00 $0 $0 $0 $0 Routine blood, urine, cholesterol tests $235.00 $100.00 $0 $0 $0 $0 Thyroid Test $29.00 $11.00 $11.00 Total $589.00 $311.00 $11.00

• Your total responsibility in this situation is $11.00.
• Annual physicals are covered at $0 copayment.
• Select routine preventive tests are covered at no charge.
• Diagnostic labs are subject to your deductible.

* Provider Charge and Allowed Amounts are just examples and not actual costs for services listed.

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Example:

Service Provided Provider Charge Allowed Amount Deductible Applied What copay you would pay at a Tier 1 provider

• r hospital

What copay you would pay at a Tier 2 provider

• r hospital

What copay you would pay at a Tier 3 provider

• r hospital

Office visit to

• rthopedic DR.

$400.00 $175.00 $0 $30 $60 $75 MRI (subject to deductible) $1,300.00 $900.00 $500.00 $100.00 $100.00 $100.00 In Patient Surgery $6,750.00 $4,025.00 $0 (deductible met) $275 $500.00 $1000.00 Total $8,450.00 $5,100.00 $500.00 $405.00 $660.00 $1175.00

• You are referred to an orthopedic specialist for knee pain. The provider

recommends a MRI. After the MRI it is confirmed you need knee surgery. At this point you have incurred no other deductible expenses.

• Your financial responsibility varies based on the tier of the provider and hospital you chose.
• Tier 1 Provider and Hospital – total responsibility is $905.00 (deductible and copays)
• Tier 2 Provider and Hospital – total responsibility is $1160.00 (deductible and copays)
• Tier 3 Provider and Hospital – total responsibility is $1675.00 (deductible and copays)

* Provider Charge and Allowed Amounts are just examples and not actual costs for services listed.

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Example:

Service Provided Provider Charge Allowed Amount Deductible Applied What copay you would pay at a Tier 1 provider

• r hospital

What copay you would pay at a Tier 2 provider

• r hospital

What copay you would pay at a Tier 3 provider

• r hospital

Office visit to PCP $220.00 $101.00 $0 $10 $20 $40 Strep Test $42.00 $30.00 $15.00 Total $262.00 $131.00 $15.00

• Your bring your child to their PCP due to illness. PCP orders a test for

strep throat. At this point you have satisfied $985.00 of your family deductible.

• Your financial responsibility varies based on the tier of your PCP.
• Since you have already satisfied some of your family deductible, for services subject to the

deductible you are only responsible for charges up to the deductible amount.

• Tier 1 PCP – total responsibility is $25.00 (remaining deductible and copay)
• Tier 2 PCP – total responsibility is $35.00 (remaining deductible and copay)
• Tier 3 PCP – total responsibility is $55.00 (remaining and copay)

* Provider Charge and Allowed Amounts are just examples and not actual costs for services listed.

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Prescription Drug Example

Service Provided Pharmacy Billed Amount Allowed Amount Deductible Applied Your copayment Lisinopril 20 mg tablet 30 days $38.52 $3.24 $3.24 Total $38.52 $3.24 $3.24

• You go to the pharmacy to pick up a 30 day supply of Lisinopril at CVS.

You have not yet satisfied any of your RX deductible.

• Since you have not satisfied your deductible you are responsible for the contracted price of the

drug.

• Copayments do not apply until you have satisfied your deductible.
• Once the deductible is satisfied you will be responsible for a copayment determined by the tier of

the medication

* Pharmacy Charge and Allowed Amounts are just examples and not actual costs for services listed.

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Your Activity Summary

Sent once we receive a claim for your services.

Date and type of service, plus provider name Retail price, negotiated price and amount charged to the member’s deductible Deductible and Out Of Pocket Maximum Accumulator

• Accumulator info for entire family displays on the subscriber’s

statement.

• Subscriber’s statement shows deductible and OOP

max for every member on the contract.

• Dependent’s statement only displays his/her own

deducible and OOP max information.

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Finding Your Provider

• 1. Go to www.harvardpilgrim.org
• 2. Click on Find a provider in

upper banner

• 3. Click on Tiered/Limited

Choicenet HMO 2018 or Choicenet PPO 2018

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Finding Your Provider

• Enter zip code, address or doctor name to

search for providers in your area

• Filter by provider specialty if necessary
• Providers are tiered at the PCP and Specialist

levels:

• PCP: T1: $10 T2: $20 T3: $40
• Specialists: T1: $30 T2: $60 T3: $75

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Helpful resources for members @ www.harvardpilgrim.org www.harvardpilgrim.org

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• Drug tier look-up
• Provider Look Up
• The Learning Center
• Discount Programs
• The Learning Center
• HPHConnect
• Online Transparency Tool
• Look up costs of services

and prescription drugs to help estimate out of pocket expenses.