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 2

Examples: • You visit your PCP for your routine annual physical Service Provider Allowed Deductible What you would What you would What you would Provided Charge Amount Applied pay at a Tier 1 pay at a Tier 2 pay at a Tier 3 provider or provider or provider or hospital hospital hospital Annual Wellness $325.00 $200.00 $0 $0 $0 $0 Visit Routine blood, $235.00 $100.00 $0 $0 $0 $0 urine, cholesterol tests 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. 3

Example: • 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. Service Provider Allowed Deductible What copay you What copay you What copay you Provided Charge Amount Applied would pay at a would pay at a would pay at a Tier 1 provider Tier 2 provider Tier 3 provider or hospital or hospital or hospital Office visit to $400.00 $175.00 $0 $30 $60 $75 orthopedic DR. MRI $1,300.00 $900.00 $500.00 $100.00 $100.00 $100.00 (subject to deductible) In Patient $6,750.00 $4,025.00 $0 $275 $500.00 $1000.00 Surgery (deductible met) Total $8,450.00 $5,100.00 $500.00 $405.00 $660.00 $1175.00 • 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. 4

Example: • 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. Service Provider Allowed Deductible What copay you What copay you What copay you Provided Charge Amount Applied would pay at a would pay at a would pay at a Tier 1 provider Tier 2 provider Tier 3 provider or hospital or hospital or hospital Office visit to $220.00 $101.00 $0 $10 $20 $40 PCP Strep Test $42.00 $30.00 $15.00 Total $262.00 $131.00 $15.00 • 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. 5

Prescription Drug Example • 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. Service Pharmacy Allowed Deductible Your Provided Billed Amount Amount Applied copayment Lisinopril 20 mg $38.52 $3.24 $3.24 tablet 30 days Total $38.52 $3.24 $3.24 • 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. 6

Your Activity Summary Sent once we receive a claim for your services. 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. Date and type of service, plus provider name Retail price, negotiated price and amount charged to the member’s deductible 7

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 8

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 9

Helpful resources for members @ www.harvardpilgrim.org www.harvardpilgrim.org  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. 10 10