NH Local Choice HMO Silver 1100 CSR87 – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $40 copay after deductible
Urgent care visit: $30 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,100 per person $1,100 per person |
| Out-of-pocket max | $1,850 per person $3,700 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | $300 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $500 copay per Stay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $500 copay after deductible |
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 | No charge after deductible |
| Imaging (CT/PET/MRI) | $40 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | $500 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.harvardpilgrim.org/rest/eoc/content/sbc/PD0000201048.pdf |
| Drug and medication plan formulary | https://www.harvardpilgrim.org/2024CoreNH5T |
| Search doctor list | https://www.harvardpilgrim.org/public/NHLocalChoiceDir |