N.H. Admin. Code Ins, ch. Ins 400, pt. Ins 403, app A
Benefits | HealthFirst Plan |
Preventive Care Services: Immunizations, Lead Screenings, PSA, Routine Physical Exams (including family planning, pre-natal & well child care), annual ob-gyn visits (including mammography), Routine Hearing Laboratory and an Annual Care Plan for Chronic Illnesses | Covered in Full |
Other Office Visits: Primary Care Copay Specialist Copay Colonoscopy | $20 per visit $50 per visit Subject to $250 copay |
Deductible (single family traditional) Coinsurance Max out of pocket (single/family traditional) | Tier 1 Facilities: $2,500/$5,000 Tier 2 Facilities: $4,000/$8,000 None $5,000/$10,000 |
Lifetime Maximum | No maximum |
In/Out Patient Hospital Care | Subject to deductible, including diagnostic lab |
Skilled Nursing & Rehab Facilities: SNF limited to 100 days/CY, Rehabilitation Facility limited to 60 days/CY | Subject to deductible |
Diagnostic Labs and X-Rays: Labs X-Rays MRI, CT and PET Scans | Covered in full Subject to deductible Subject to deductible |
Outpatient Surgery: Doctor's Office Hospital/Surgical Day Care | $20/$50 per visit Subject to deductible |
Urgent/Emergency Room Care: Urgent Care Facility Copay Emergency Room Facility Copay | $100 per visit for the facility charge. All other services are subject to the Tier 1 or Tier 2 deductible. $200 per visit |
Ambulance (medically necessary) | Subject to deductible |
Short Term Therapy (PT, OT, ST) | $50 per visit |
Chiropractic | Not covered |
Mental Health/Substance Abuse Services: Office Visits Facility | $20 per visit Subject to deductible |
Durable Medical Equipment: Limited to $3,000/Mbr/CY | Subject to deductible |
Prescription Drugs: Covered medication, diabetic supplies and contraception devices purchased at a network pharmacy Certain maintenance drugs are available for a supply greater than 30 days. Maximum out-of-pocket (single/family traditional) Important Notes: If, due to medical necessity, your physician prescribes a brand drug, you pay only the formulary or non-formulary brand copay shown on this summary. For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each covered benefit therapeutic class. | $10 copay/generic $35 copay/formulary brand $50 copay/non-formulary brand No Max Copayment applies to each 30 day supply. $5,000/$10,000 |
Members are required to work with a care navigator for certain tests and procedures. | |
Members shall establish a relationship with a primary care provider. | |
The benefit plan shall additionally cover the following services: Screening and Brief Intervention for Alcohol and Drug Abuse Body Mass Index Screening After-hours care |
N.H. Admin. Code Ins, ch. Ins 400, pt. Ins 403, app A