NH Local Choice HMO Bronze 6500 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$6,500 per person $6,500 per person
Out-of-pocket max	$8,900 per person $17,800 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$40 copay, 20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	$500 copay after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	30% coinsurance after deductible
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.harvardpilgrim.org/rest/eoc/content/sbc/PD0000201086.pdf
Drug and medication plan formulary	https://www.harvardpilgrim.org/2024CoreNH5T
Search doctor list	https://www.harvardpilgrim.org/public/NHLocalChoiceDir