NH Local Choice HMO Silver 2500 – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $50 copay

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Description

Health Care Plan Details

Network type HMO
Deductible $2,500 per person $2,500 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Silver

Visit Copay

Primary care visit $40 copay
Specialist visit $80 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
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 $60 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $100 copay
Non-preferred Brand 30% 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 $40 copay
Psychiatric hospital stay 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.harvardpilgrim.org/rest/eoc/content/sbc/PD0000201026.pdf
Drug and medication plan formulary https://www.harvardpilgrim.org/2024CoreNH5T
Search doctor list https://www.harvardpilgrim.org/public/NHLocalChoiceDir