HPHC PPO MEDICAL PLAN with HRA The Harvard Pilgrim Health Care (HPHC) PPO Medical plan with the London Health Administrators Health Reimbursement Arrangement (HRA) integrates a fully insured component from HPHC and a self-funded component from ABC Company Technologies into a single benefit package. The HPHC coverage includes an annual in-network, per individual deductible services that apply to the in-network deductible members have no deductible responsibility. ABC Company Technologies, via London of $3,000 ($6,000 family maximum). On Health, also funds a portion and/or all the copayments for office visits, specialist visits, urgent care, diagnostic tests, high tech imaging, inpatient hospitalization, outpatient surgery and prescriptions. HPHC Plan Cost HRA Pays YOU Pay In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Deductible (Ind/Family) $3,000 / $6,000 $6,000/$12,000 $3,000 / $6,000 $5,500/$11,100 $0 $500/$1,000 Out-of-Pocket Max (Ind/Family) $8,500 / $17,000 $17,000/$34,000 n/a n/a $8,500/$17,000 $17,000/$34,000 Coinsurance n/a 20% after deductible n/a 0% n/a 20% Preventive Visit $0 $0 $0 PCP Office Visit $40 copay $25 copay $15 copay Specialist Visit & Urgent Care $65 copay $25 copay $40 copay deductible deductible deductible Diagnostic X-Ray/Bloodwork then then then Flex Provider $0 20% coinsurance $0 20% coinsurance $0 20% coinsurance Other Provider deductible then $65 copay deductible then $65 copay $0 High Tech Imaging Non-Hospital $250 copay $125 copay $125 copay Hospital deductible then $750 copay deductible then $625 copay $125 copay Emergency Room deductible then $650 copay deductible then $525 copay $125 copay Inpatient Care deductible then $1,000 copay deductible then $1,000 copay $0 deductible deductible deductible Outpatient Care then then then Flex Provider $250 copay 20% coinsurance $250 copay 20% coinsurance $0 20% coinsurance Other Provider deductible then $750 copay deductible then $750 copay $0 Prescriptions Retail 30 Day Supply $5 / $30 / $80 / $120 / 20% to $500 50% $2.50 / $15 / $40 / $60 / 50% Mail 90 Day Supply $10 / $60 / $160 / $360 /20% to $1,500 50% $5 / $30 / $80 / $180 / 50% [ 8 ]