Page 14 - Harvard Maintenance HSS 2022 Benefits Guide

Calendar Year 2022
Benefits Enrollment

Open Access Plus (PPO) Plan

Plan Highlights In-Network Out-of-Network*
Annual Calendar Year Deductible
Individual $1,200 $4,800
Emp + 1 Dependent (Spouse Or Child) $2,400 $9,600
Family $2,400 $9,600
Maximum Calendar Year Out-of-Pocket
Individual $4,500 $30,000
Emp + 1 Dependent (spouse or child) $9,000 $60,000
Family $9,000 $60,000
Professional Services
Primary Care Physician (PCP) Oice Visit $25 copay 30% coinsurance
Specialist Oice Visits $50 copay 30% coinsurance
Preventative Care Exam Covered 100% 30% coinsurance
Well-Baby Care Covered 100% Covered 100%
Diagnostic Lab and X-Ray (after deductible) Lab: 20% coinsurance Lab: 50% coinsurance
X-ray: 20% coinsurance X-ray: 50% coinsurance
Complex Diagnostics (MRI/CT scan) 20% coinsurance 50% coinsurance
(after deductible)
Chiropractic $50 copay 30% coinsurance
Therapy, Including Physical, Occupational, and $50 copay 30% coinsurance
Speech (30 visits per calendar year combined)
Hospital Services (after deductible)
Inpatient 20% coinsurance 50% coinsurance after $500 per visit
deductible
Outpatient Services 20% coinsurance 50% coinsurance
Emergency Use of Ambulance 20% coinsurance 20% coinsurance
Emergency Room (deductible waived) $200 copay $200 copay
Urgent Care $35 copay; deductible waived 30% coinsurance
Maternity Care (after deductible)
Inpatient Hospital Services 20% coinsurance 50% coinsurance after $500 per
admission deductible
Mental Health Services (after deductible)
Inpatient Covered 100%; deductible waived 30% coinsurance after $500 copay;
after deductible
Mental Health Oice Visits Covered 100%; deductible waived 30% coinsurance
Recovery Services (after deductible)
Home Healthcare (60 visits per calendar year) 20% coinsurance 25% coinsurance
Skilled Nursing Care (60 days per calendar year) 20% coinsurance 50% coinsurance after $500 per visit
deductible
Prescription Drugs (30-day supply)
Preferred Generic Drugs (Tier 1) $10 copay 30% coinsurance
Preferred Brand-Name Drugs (Tier 2) $40 copay after Rx deductible of 30% coinsurance after Rx deductible
$200 individual/$400 family $200/$400
Non-Preferred (Tier 3) $60 copay after Rx deductible of 30% coinsurance after Rx deductible
$200 individual/$400 family $200/$400
* All out-of-network services are after the plan deductible unless otherwise stated .

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