NH Local Choice HMO Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $50 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $300 copay |
| Ambulance | 25% coinsurance |
| Hospital stay (facility) | 25% coinsurance |
| Hospital stay (physician) | 25% coinsurance |
| Outpatient procedure (facility) | 25% coinsurance |
| Outpatient procedure (physician) | 25% coinsurance |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $60 copay |
| Non-preferred Brand | 35% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance |
| Imaging (CT/PET/MRI) | 25% coinsurance |
| Blood work | 25% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | 25% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.harvardpilgrim.org/rest/eoc/content/sbc/PD0000201021.pdf |
| Drug and medication plan formulary | https://www.harvardpilgrim.org/2024CoreNH5T |
| Search doctor list | https://www.harvardpilgrim.org/public/NHLocalChoiceDir |
