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Submitting as an Individual
Submitting as a Family
(It does not matter if you are enrolled (You must be enrolled with Family
in Individual or Family coverage.)
coverage to submit as a family.)
In-Network
Office Visits
Prescription
Drug
In-Network
Office Visits
Prescription
Drug
$135
$270
$500
$1,000
$330
$660
$1,000
$2,000
* This program is only available to employees with an annual full-time equivalent salary less than or equal to $95,000. Full-time
equivalent salary is your annual salary if you work full-time, or for those who work less than full-time, the salary that would be earned
working full-time at the same rate of pay.
$0.253
$0.289
$0.623
$0.786
Monthly Cost
per $1,000 of
Insurance
$ 0.028
$ 0.034
$ 0.040
$ 0.047
$ 0.058
$ 0.085
$ 0.134
$ 0.211
$ 0.269
$ 0.491
$ 0.783
$ 1.438
$ 2.058
VISION CARE
Davis Vision
Monthly Cost
Individual
Family
$5.43
$12.49
DENTAL
Delta Dental
Monthly Cost
Individual
Family
$15.94
$45.07
DENTAL BENEFITS
Delta Dental Covered Services
Preventive Care
Basic Restorative
Services
Periodontics,
Endodontics and Oral
Surgery
Major Restorative
Services
Orthodontics
Covered in full
75% coverage, after
deductible
75% coverage, after
deductible
LONG TERM
DISABILITY COST
SUPPLEMENTAL
LIFE INSURANCE COST
Maximum Annual
Benefit
Annual Deductible
$81
$123
$157
$94
$136
$170
$110
$152
$186
$123
$165
$199
$123
$165
$199
5. Multiply by 12 to determine
your annual cost.
J-FULLBENEFITS-COMPCHART-2014 -NON-UNION
$70,000 $95,000
*Full-time equivalent salary is your annual salary if you work full-time, or for those
who work less than full-time, the salary that would be earned working full-time at the
same rate of pay.
INDIVIDUAL COVERAGE
Less than
$70,000
FAMILY COVERAGE
Medical Plan Options
$70,000 $95,000
More than
$95,000
$218
$331
$422
$256
$369
$460
$296
$409
$500
$337
$450
$541
$337
$450
$541
HARVARD UNIVERSITY MEDICAL PLAN DECISION & COMPARISON CHART FOR 2014
HMO (Health Maintenance Organization)
In-Network (Authorized)
Out-of-Network (Unauthorized)
In-Network (Authorized)
Out-of-Network (Unauthorized)
Care must be provided or authorized by your primary care physician (PCP) chosen from within
your Plans network.
Care must be provided by a participating provider in order Care is received from non-participating provider.
to receive in-network level of benefits.
None
None
None
$2,000 individual/$6,000 family. (Prescription drug costs do not count toward out-of-pocket maximum.)
$2,500 individual coverage/$7,500 family coverage. Once annual outof-pocket maximum is met, POS pays 100% of usual, customary and
reasonable (UCR) 3 covered charges.
100%
100%
100%
100%
100%
80% of UCR
100%
80% of UCR
100%
100%
80% of UCR
100%
80% of UCR
Preventive Services
100%
100%
80% of UCR
100%
80% of UCR
Physicians Services
Surgical Fees
Inpatient - 100%
Outpatient - $20 copayment
Inpatient 100%
Outpatient $20 copayment
80% of UCR
Inpatient - 100%
Outpatient - $20 copayment
80% of UCR
In-hospital visits
100%
100%
80% of UCR
100%
80% of UCR
$20 copayment
$20 copayment
80% of UCR
$20 copayment
80% of UCR
Mental Health
Inpatient - 100%
Outpatient - $20 copayment
Inpatient - 100%
Outpatient - $20 copayment
Inpatient - 100%
Outpatient - $20 copayment
Substance Abuse
Inpatient - 100%
Outpatient - $20 copayment
Inpatient - 100%
Outpatient - $20 copayment
Inpatient - 100%
Outpatient - $20 copayment
Maternity
100%
100%
80% of UCR
100%
80% of UCR
Emergency Care
$7 copayment for generic, $20 for preferred brand, $45 for non-preferred brand at a participating pharmacy
$7 copayment for generic, $20 for preferred brand, $45 for non-preferred
brand at a participating pharmacy
$14 copayment for generic, $50 for preferred brand, $110 for non-preferred brand from Express Scripts
pharmacy
$14 copayment for generic, $50 for preferred brand, $110 for non-preferred
brand from Express Scripts pharmacy
$14 copayment for generic, $50 for preferred brand, $110 for nonpreferred brand from Express Scripts pharmacy
$14 copayment for generic, $50 for preferred brand, $110 $14 copayment for generic, $50 preferred brand, $110
for non-preferred brand from Express Scripts pharmacy
non-preferred brand from Express Scripts pharmacy
Physical Therapy
Chiropractic Care
Dependent Coverage
Spouse, same-sex or opposite sex domestic partner, and children under age 26
Spouse, same-sex or opposite sex domestic partner, and children under age 26
Spouse, same-sex or opposite sex domestic partner, and children under age 26
Network
Primary care network consists of HUHS and Atrius Health group practices.
Access to Blue Cross Blue Shield specialty and hospital provider network.
More than 28,000 doctors and 149 hospitals across the region.
$20 copayment. If HUHS PCP, full access (24 hours, 365 days). If no HUHS
PCP, access is for employees only during work hours.
$20 copayment for urgent care only for employees only, during work hours.
$20 copayment for urgent care only for employees only, during work hours.
Other
HPHC authorization required before any costs are incurred for certain specialized out-of-network services: Inpatient
care, day surgery, physical, speech, and occupational therapy, advanced reproductive technologies, mental health, all
home services, and organ transplants.