Page 15 - Harvard Maintenance HSS 2022 Benefits Guide

Calendar Year 2022
Benefits Enrollment

Open Access Plus

High Deductible Health Plan (HDHP)

Plan Highlights In-Network* Out-of-Network*
Annual Calendar Year Deductible
Individual $2,800 $10,000
Family $5,600 $20,000
Maximum Calendar Year Out-of-Pocket
Individual $5,000 $30,000
Family $10,000 $60,000
Professional Services (after deductible)
Primary Care Physician (PCP) Oice Visit 20% coinsurance 50% coinsurance
Specialist Oice Visits 20% coinsurance 50% coinsurance
Preventative Care Exam Covered 100%; deductible waived 30% coinsurance
Well-Baby Care (deductible waived) 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 20% coinsurance 50% coinsurance
Therapy, Including Physical, Occupational, and 20% coinsurance 50% coinsurance
Speech (30 visits per calendar year combined)
Hospital Services (after deductible)
Inpatient 20% coinsurance 50% coinsurance
Outpatient Services 20% coinsurance 50% coinsurance
Emergency Use of Ambulance 20% coinsurance 20% coinsurance
Emergency Room 20% coinsurance 20% coinsurance
Urgent Care 20% coinsurance 30% coinsurance
Maternity Care (after deductible)
Inpatient Hospital Services 20% coinsurance 50% coinsurance
Mental Health Services (after deductible)
Inpatient 20% coinsurance 50% coinsurance
Mental Health Oice Visits 20% coinsurance 50% coinsurance
Recovery Services (after deductible)
Home Healthcare 20% coinsurance 25% coinsurance
(40 visits per calendar year)
Skilled Nursing Care 20% coinsurance 50% coinsurance
(60 days per calendar year)
Prescription Drugs** (30-day supply) (after deductible)
Preferred Generic Drugs (Tier 1) $10 copay 20% coinsurance after deductible
Preferred Brand-Name Drugs (Tier 2) $40 copay 20% coinsurance after deductible
Non-Preferred (Tier 3) $60 copay 20% coinsurance after deductible
* Unless otherwise indicated, the deductible must be met prior to beneits being payable.
** The full cost of the drug is applied to the deductible before any beneits are considered for payment under the pharmacy plan.

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