NH Local HMO Gold 1500 Standard - 59025NH0370084 Health Insurance Plan

Coverage is not provided for abortion, except when the life of the mother is endangered or when the pregnancy is a result of rape or incest.

Coverage for treatment resulting from accidental injury to sound natural teeth and gums. Repairs to teeth with damage resulting from normal activities of daily living or extraordinary use of the teeth is not covered.

There is no visit limit for Acupuncture, however member cost sharing applies.

In order to receive coverage for bariatric surgery, care must be received from a designated center of excellence. To verify a provider's status, refer to the online provider directory.

Coverage is not provided for adult dental care.

Coverage is not provided for pediatric dental care.

Provided in a Hospital- Acute Inpatient setting.

Provided in a Hospital-Outpatient setting.

There is no visit limit for Chiropractic Care, however member cost sharing applies.

48 Hour Minimum Stay-Vaginal; 96 Hour Minimum Stay-Cesarean.

Provided in a Hospital- Acute Inpatient setting.

Coverage is not provided for pediatric dental care.

The Plan covers outpatient self-management education and training for the treatment of diabetes, including medical nutrition therapy services, used to diagnose or treat insulin-dependent diabetes, non-insulin dependent diabetes, or gestational diabetes. Services must be provided on an individual basis and be provided by a Plan Provider

Plan approval required for dialysis services when temporarily traveling outside of the state where you live. Such coverage is only provided for up to 30 days per calendar year.

One breast pump per birth (rented or purchased)

Limit: 40.0 Visit(s) per Year

For Members under the age of 3, coverage is available for services rendered by occupational therapists, physical therapists, speech-language pathologists and clinical social workers

Emergency room copayments are waived when a member is directly admitted to the hospital.

If you have a Medical Emergency, your Plan covers ambulance transport to the nearest Hospital that can provide care.

Limit: 1.0 Item(s) per Year

Each dependent under the age of 19 is covered every 12 months for either (a) 1 pair of standard or basic eyeglass frames and lenses or (b) contact lenses. Limits apply, refer to the Schedule of Benefits.

Provided in a Hospital- Acute Inpatient setting.

Certain preventative services are covered at no cost to the member. See a complete list at harvardpilgrim.org Coverage for some generic OTC medications is available at tier 1 Rx cost sharing. You can use the drug lookup tool at harvardpilgrim.com/rx to search the formulary for OTC medications you may be taking. Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Coverage is limited to 1 hearing aid per hearing-impaired ear when medically necessary.

Provided in a Hospice-Outpatient setting.

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Covered benefits include consultation, evaluation and laboratory testing. Coverage is also provided for services to treat underlying medical conditions that may cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Infertility drugs and treatment such as therapeutic donor insemination and advanced reproductive technologies are excluded from coverage.

Provided in a Hospital-Outpatient setting.

Limit: 100.0 Days per Year

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their lab services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Coverage is not provided for adult dental care.

Coverage is not provided for pediatric dental care.

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Coverage is not provided for adult dental care.

Coverage is not provided for pediatric dental care.

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Members save money by obtaining a 90-day supply of tier 2 maintenance medications through our mail order pharmacy.

Routine Prenatal and Postnatal Care are covered in full.

Certain preventive services as defined in Federal law are covered with no Out-Of-Pocket cost to member when provided by a Plan Provider.

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Coveage is provided for (a) the least costly prosthetic device adequate to allow you to perform Activities of Daily Living. Activities of Daily Living do not include special functions needed for occupational purposes or sports; and (b) one item of each type of prosthetic device. No back-up items or items that serve a duplicate purpose are covered.

Provided in a Hospital-Outpatient setting.

Provided in a Hospital- Acute Inpatient setting.

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Limit: 1.0 Exam(s) per 2 Years

Adults are covered for one routine eye exam every 2 years.

Limit: 1.0 Exam(s) per Year

Members under the age of 19 are covered for one routine eye exam every year.

Excluded, except for preventive foot care for members with diabetes or systemic circulatory diseases.

Limit: 100.0 Days per Year

Coverage limited to 100 days per year. Custodial or Long Term Care is not covered.

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Provided in a Hospital- Acute Inpatient setting.

Exclusions: No dental care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.

Provided in a Surgery-Outpatient setting.

Urgent care centers can be both freestanding and hospital-based. Receiving care from freestanding urgent care clinics often has lower member out of pocket cost. To locate freestanding urgent care clinics in our network, search for 'Urgent Care Center' provider type in the online provider directory.

There is no coverage for weight loss programs. Members can get reimbursement for a fitness club membership or virtual fitness class subscription. Learn more by visiting harvardpilgrim.org/fitnessreimbursement. Through our partner, WebMD, program members can earn rewards for participating in a variety of informative and interactive activities that supports all aspects of well-being, including healthy eating, physical activity, financial wellness, mindfulness and meditation, self-care and stress management This program is a subscriber-only program and participants can earn up to $120 in rewards per year.

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.