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NH Local Choice HMO Silver 3500 + $0 Rx list + $0 Virtual Urgent Care
Harvard Pilgrim Health Care · 2027 plan year
Silver
- Ind. deductible
- $3,500
- Family deductible
- $7,000
- Ind. OOP max
- $10,000
- Family OOP max
- $20,000
Other cost-sharing reduction variants for this plan:
More Harvard Pilgrim Health Care plans in NH
Monthly premiums by age
Rating Area 1
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $453 | $453 |
| 21 | $593 | $753 |
| 30 | $673 | $854 |
| 40 | $758 | $962 |
| 50 | $1,059 | $1,345 |
| 60 | $1,609 | $2,043 |
| 64 and over | $1,778 | $2,258 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $40.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $85.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $500.00 Copay after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | $1000.00 Copay per Stay after deductible |
| Outpatient Surgery Physician/Surgical Services | No Charge after deductible |
| Urgent Care Centers or Facilities | $50.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $10.00 |
| Non-Preferred Brand Drugs | 35.00% Coinsurance after deductible |
| Off Label Prescription Drugs | 35.00% Coinsurance after deductible |
| Preferred Brand Drugs | $60.00 Copay after deductible |
| Specialty Drugs | 45.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | $1000.00 Copay per Stay after deductible |
| Mental/Behavioral Health Outpatient Services | $40.00 |
Other
| Benefit | In-network |
|---|---|
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $40.00 |
| Acupuncture | Not covered |
| Allergy Testing | 20.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies | No Charge after deductible |
| Bariatric Surgery | $1000.00 Copay after deductible |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | $1000.00 Copay after deductible |
| Chemotherapy | 20.00% Coinsurance after deductible |
| Chiropractic Care | $40.00 |
| Convenience Care Clinic | $40.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $1000.00 Copay after deductible |
| Dental Anesthesia | $1000.00 Copay after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $40.00 |
| Diabetes Education | $85.00 |
| Dialysis | 20.00% Coinsurance after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Early Intervention Services | No charge |
| Emergency Transportation/Ambulance | 20.00% Coinsurance after deductible |
| Eye Glasses for Children | 50.00% |
| Gender Affirming Care | $1000.00 Copay after deductible |
| Habilitation Services | $60.00 Copay after deductible |
| Hearing Aids | 50.00% |
| Home Health Care Services | 20.00% Coinsurance after deductible |
| Hospice Services | 20.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | $75.00 Copay after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 20.00% Coinsurance after deductible |
| Inherited Metabolic Disorders - PKU | 20.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Inpatient Rehabilitation Services | $1000.00 Copay after deductible |
| Laboratory Outpatient and Professional Services | 20.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Low Protein Foods | 20.00% Coinsurance after deductible |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $40.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $250.00 Copay after deductible |
| Outpatient Rehabilitation Services | $60.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | 20.00% Coinsurance after deductible |
| Reconstructive Surgery | $1000.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $60.00 Copay after deductible |
| Rehabilitative Speech Therapy | $60.00 Copay after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | $40.00 |
| Routine Eye Exam for Children | $40.00 |
| Routine Foot Care | $85.00 |
| Skilled Nursing Facility | $1000.00 Copay per Stay after deductible |
| Substance Abuse Disorder Inpatient Services | $1000.00 Copay per Stay after deductible |
| Substance Abuse Disorder Outpatient Services | $40.00 |
| Transplant | $1000.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | $250.00 Copay after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| Wigs | 20.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 20.00% Coinsurance after deductible |
Service area
This plan covers 1 geographic area.
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