RXINSIDER 2025
PPO Plan
The PPO plan gives you the freedom to seek care from the provider of your choice.
However, you will maximize your bene�ts and reduce your out-of-pocket costs if you
choose a provider participating in the (carrier name/network name) network. The
calendar year deductible must be met before certain services are covered.
Harvard Pilgrim HealthCare – Medical Bene�t Summary
Deductible
• Employee Only
• Family
$1,500
$3,000
Out-of-Pocket Limit
• Employee Only
• Family
$8,500
$17,000
Preventive Care
Primary Care Visit to Treat an Illness or Injury
Specialist Visit
Emergency Room
Urgent Care
No Charge
$30/Copay
$50/Copay
$250/Copay
$50/Copay
Prescription Drugs
Retail
• Tier 1 Generic Drugs
• Tier 2 Preferred Brand and Some Generic
• Tier 3 Non-Preferred Brand drugs
$5/Copay
$30/Copay
$60/Copay
Mail Order
• Tier 1 Lowest Cost Generic Drugs
• Tier 2 Low-Cost Generic Drugs
• Tier 3 Higher Cost Generic and Preferred Brand Name Drugs
$10/Copay
$60/Copay
$180/Copay
Harvard Pilgrim Health Care