©P9 Harvard Pilerim
iy HealthCare’
Tlarvard Pilurim Wealth Care includes Harvard Pilgrim Health Care,
Harvard Pilgrio Health Care of Connecticut, Harvard Pilgrim
Tealth Care of New England and HPIIC Insurance Company.
RATE PROPOSAL
Company Name: City of Nashua
Group Number: 027219
Effective Date: 07/01/2016 - 06/30/2017
Plan ID :MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option
-T
Subtotal: Admin & Reinsurance
CAR Total (Claims & Admin &
PURCHASED OPTION * FEES
Fitness Club Reimbursement Program $0.00 PEPM Flat Fee
Fitness Reimbursement Max $150.00 PSPCY Level
BENEFITS SUMMARY (Refer to the Schedule of Benefits for benefit details)
Office Visit $20
Emergency Room $100
Inpatient Services DED
Day Surgery DED
Coinsurance In-Network None
Coinsurance Out of Network NA
Deductible In-Network Individual $250 PPY
Deductible Out of Network Individual NA
Deductible In-Network Family $500 PPY
Deductible Out of Network Family NA
Gut of Pocket Maximum In-Network Individual $6,450 PPY
Out of Pocket Maximum Out of Network Individual | NA
Out of Pocket Maximum In-Network Family $12,900 PPY
Out of Pocket Maximum Out of Network Family NA
Chiropractic Care 12 visits PPY
Rx Copay 30 Days $5/$15/$35/NA/NA
Rx Copay Mail Order $5/$30/$70/NA/NA
Cross Accumulation Cross Accumulated
Rx Copay Deductible N/A
OOP Max Individual Rx $6450
OOP Max Family Rx $12900
Formulary Premium
* In the event that you purchase or have purchased a specialty care and disease management program, please note that specialty care and
disease management program Service Fees must be paid for minimum onc-year periods and no retroactive termination of members is permitted.
*Deductibles and Out of Pocket Maximums are Per Calendar Year (PCY) unless otherwise indicated to be Per Plan Year (PPY)
Max OOP=Maximum Out of Pocket, Chiro=Chiropractic Rider, Rx=Prescription, PCY=Per Calendar Year, OV=Office Visit, IN=In Network,
OON=Out of Network, ER=Emergency Room, PMPM=Per Member Per Month, PEPM=Per Employee Per Month, PDMPM=Per Diseased
Member Per Month, PSPC Y=Per Subscriber Per Calendar Year
Form No. 1207 Printed Date: 03/29/16
