HMO Standard PPO Standard PPO HSA In Network In Network Out of Network In Network Out of Network Deductible (Ind/Fam) None None $500 / $1,000 $1,700 / $3,400 $3,000 / $6,000 Out of Pocket Maximum (Ind/Fam) $6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $3,300 / $6,600 $6,000 / $12,000 Office Visit PCP Visit $20 $20 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible Specialist Visit $20 $20 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible Emergency Room $100 $100 $0 after deductible X-Rays, Lab Tests Covered in Full Covered in Full 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible MRI, CT Scans Covered in Full Covered in Full 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible Inpatient Hospital Covered in Full Covered in Full 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible Outpatient Hospital Covered in Full Covered in Full 20% coinsurance after deductible $0 after deductible 20% coinsurance after deductible Prescription Drugs download: Select 4-Tier Prescription Drug Coverage Overview download: HMO & PPO Prescription Drug Summary download: PPO HSA Prescription Drug Summary Retail (30-day supply) Deductible applies, then: Deductible applies, then: Generic $10 $10 $10 $10 $10 Preferred Brand $25 $25 $25 $25 $25 Non-Preferred Brand $40 $40 $40 $40 $40 Specialty 20% to $250 per script 20% to $250 per script 20% to $250 per script 20% to $250 per script 20% to $250 per script Mail Order (90-day supply) Deductible applies, then: Deductible applies, then: Generic $20 $20 $20 $20 $20 Preferred Brand $50 $50 $50 $50 $50 Non-Preferred Brand $80 $80 $80 $120 $120 Specialty 20% to 750 per script 20% to $750 per script 20% to $750 per script 20% to $750 per script 20% to $750 per script The HMO plan is a network only plan. Employees enrolling in this plan will need to name a Primary Care Physician and receive care in the Harvard Pilgrim network in order to receive coverage. The PPO plan provides coverage should employees want to receive care outside the HPHC network. Employees do not need to name a PCP and can self-refer to see a specialist. The PPO HSA plan has the same network and features as the PPO plan. All services are subject to the deductible on this plan (outside of preventive). This plans allows for employees to open a tax advantaged Health Savings Account. Westfield Capital Management offers three medical plan options through Harvard Pilgrim Healthcare. MEDICAL PLAN COMPARISON 5 // 2026 Employee Benefit Guide download: HMO Standard SOB download: PPO Standard SOB download: PPO HSA SOB download: HMO Coverage Guide download: PPO Coverage Guide download: PPO HSA Coverage Guide download: HMO Standard SBC download: PPO Standard SBC download: PPO HSA SBC