Harvard - ElevateHealth Gold HSA 1500

New Hampshire, 2017

  • Plan Type

    HMO

  • Metal Tier

    Gold

  • Out of Pocket Maximum

    $3,500

  • Deductible

    $1,500

Enroll Now
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Call (855) 866-5590 to speak with a licensed agent about a new health plan.

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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $1,500
Deductible (Family) $3,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $3,500
Out of Pocket Maximum (Family) $7,000

Doctor Visits

Primary Care Visit 10% Coinsurance after deductible
Specialist Visit 10% Coinsurance after deductible
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Emergency Room Services $200 Copay after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 10% Coinsurance after deductible
Laboratory Outpatient and Professional Services 10% Coinsurance after deductible
X-Ray and Diagnostic Imaging 10% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Available
Lower Back Pain Available
Pain Management Available
Pregnancy Available
Weight Loss Available

Other

Mental / Behavioral Health Inpatient 10% Coinsurance after deductible
Mental / Behavioral Health Outpatient 10% Coinsurance after deductible
Rehabilitative Speech Therapy 10% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 10% Coinsurance after deductible
Outpatient Facility 10% Coinsurance after deductible
Outpatient Surgery 10% Coinsurance after deductible

Prescription Drugs

Generic Rx $15 Copay after deductible
Preferred Brand Rx $40 Copay after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 30% Coinsurance after deductible

Other Plans in New Hampshire

Plan New Hampshire Network Silver 2500 Deductible $2,500 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Bronze HSA 6300 Deductible $6,300 Coinsurance Not applicable Out of Pocket $6,450
Plan ElevateHealth Silver 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan New Hampshire Network Gold 1000 Deductible $1,000 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Bronze 5750 Deductible $5,750 Coinsurance Not applicable Out of Pocket $7,000
Plan New Hampshire Network Bronze HSA 5100 Deductible $5,100 Coinsurance Not applicable Out of Pocket $6,550
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $1,500
Deductible (Family) $3,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $3,500
Out of Pocket Maximum (Family) $7,000

Doctor Visits

Primary Care Visit 10% Coinsurance after deductible
Specialist Visit 10% Coinsurance after deductible
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Emergency Room Services $200 Copay after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 10% Coinsurance after deductible
Laboratory Outpatient and Professional Services 10% Coinsurance after deductible
X-Ray and Diagnostic Imaging 10% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Available
Lower Back Pain Available
Pain Management Available
Pregnancy Available
Weight Loss Available

Other

Mental / Behavioral Health Inpatient 10% Coinsurance after deductible
Mental / Behavioral Health Outpatient 10% Coinsurance after deductible
Rehabilitative Speech Therapy 10% Coinsurance after deductible
Rehabilitative Occupational & Physical Therapy 10% Coinsurance after deductible
Outpatient Facility 10% Coinsurance after deductible
Outpatient Surgery 10% Coinsurance after deductible

Prescription Drugs

Generic Rx $15 Copay after deductible
Preferred Brand Rx $40 Copay after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 30% Coinsurance after deductible

Other Plans in New Hampshire

Plan New Hampshire Network Silver 2500 Deductible $2,500 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Bronze HSA 6300 Deductible $6,300 Coinsurance Not applicable Out of Pocket $6,450
Plan ElevateHealth Silver 3500 Deductible $3,500 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Silver HSA 3000 Deductible $3,000 Coinsurance Not applicable Out of Pocket $5,000
Plan New Hampshire Network Gold 1000 Deductible $1,000 Coinsurance Not applicable Out of Pocket $6,850
Plan ElevateHealth Bronze 5750 Deductible $5,750 Coinsurance Not applicable Out of Pocket $7,000
Plan New Hampshire Network Bronze HSA 5100 Deductible $5,100 Coinsurance Not applicable Out of Pocket $6,550