FULL BENEFITS

COPAYMENT REIMBURSEMENT PROGRAM

Eligible copayments are reimbursed in full once you meet the following thresholds. Copayments used to
reach the threshold, and those above the threshold, must be from a Harvard medical coverage option.
Full-Time Equivalent
Salary*

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

Less than $70,000

$70,000 to $95,000

* 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.

LONG TERM DISABILITY

FTE Salary Tier

Annual Cost per

$100 of Salary

Less than $15,000

$15,000 - $69,999
$70,000 - $95,000
More than $95,000

$0.253
$0.289
$0.623
$0.786

SUPPLEMENTAL LIFE INSURANCE

Age
Under age 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80 and over

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

CALCULATING YOUR PER PAY PERIOD COSTS

The rates shown in this Coverage Comparison chart are monthly and annual amounts.
You can determine your per pay period costs for your benefits by doing the following calculations.
MEDICAL, DENTAL
AND VISION COST

LONG TERM
DISABILITY COST

SUPPLEMENTAL
LIFE INSURANCE COST

1. Multiply your monthly

cost by 12.

1. Divide your current actual

salary by 100.

2. Divide the result by the

number of pay periods in
the calendar year:

2. Multiply the result by the

cost shown for your FTE*
Salary Tier.

Staff - 26 pay periods

Faculty - 12 pay periods
Hourly - 52 pay periods
Dining Services - 33 pay
periods

3. Divide the result by the

number of pay periods in
the calendar year:

1. Determine the amount of

Supplemental Life Insurance
you wish to purchase up to
five times your actual earned
salary (if you are faculty or staff
working less-than full-time,
this is your current actual pay,
not your FTE).

3. This equals your per pay

period cost.

Staff - 26 pay periods

Faculty - 12 pay periods
Hourly - 52 pay periods
Dining Services - 33 pay
periods
4. This equals your per pay
period cost.

Maximum Annual
Benefit

$3,000 per person

Annual Deductible

$50 per person, $150 per

family

Your Delta Dental plan provides coverage for services received

from non-participating dentists (in or out-of-state). Although
the benefit level is the same as for participating dentists, your
out-of-pocket costs will typically be higher if you use the
services of a non-participating dentist whose fees are higher
than Delta Dentals negotiated fee for those services. You will be
responsible for the difference between Delta Dentals payment
and the dentists total submitted charges for the services. Your
benefits dollar goes much further, and you enjoy greater value
from your dental plan, when you visit a participating dentist.

2014 Monthly Cost - By Salary Tier

More than
$95,000

Harvard University Group Health Plan

(HUGHP) HMO

$81

$123

$157

Harvard Pilgrim Health Care HMO

$94

$136

$170

2. Round to the nearest $1,000.

Harvard University Group Health Plan

(HUGHP) POS

$110

$152

$186

3. Divide this amount by 1,000.

Harvard Pilgrim Health Care POS

$123

$165

$199

4. Multiply the result by the

cost for your age bracket to
determine your monthly cost.

Harvard Pilgrim PPO*

$123

$165

$199

5. Multiply by 12 to determine
your annual cost.

7. This equals your per pay period

cost.
Please note that the rates on these pages apply only to those employees eligible for each of the benefits.

J-FULLBENEFITS-COMPCHART-2014 -NON-UNION

Medical Plan Options

$70,000 $95,000

Staff - 26 pay periods

Faculty - 12 pay periods
Hourly - 52 pay periods
Dining Services - 33 pay
periods

*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

6. Divide by the number of pay

periods in the calendar year:

75% coverage, after

deductible
50% coverage (no
deductible) for children
under age 19, up to
$1,500 lifetime benefit
per person

MONTHLY RATES AND HEALTH CARE COMPARISON 2014

FAMILY COVERAGE
Medical Plan Options

2014 Monthly Cost - By Salary Tier

Less than
$70,000

$70,000 $95,000

More than
$95,000

Harvard University Group Health Plan

(HUGHP) HMO

$218

$331

$422

Harvard Pilgrim Health Care HMO

$256

$369

$460

Harvard University Group Health Plan

(HUGHP) POS

$296

$409

$500

Harvard Pilgrim Health Care POS

$337

$450

$541

Harvard Pilgrim PPO*

$337

$450

$541

*Only available to employees who live outside of Massachusetts

Rates are based on your full-time equivalent salary. If you work part-time, your deduction will be
based on your full-time equivalent salary.
10/2013 - FULL BENEFITS - NON-UNION

HARVARD UNIVERSITY MEDICAL PLAN DECISION & COMPARISON CHART FOR 2014
HMO (Health Maintenance Organization)

What Type of Plan

Do You Want?

PPO (Preferred Provider Organization)

POS (Point of Service)

Employees must reside within the HMO service area

In-Network (Authorized)

Only for Employees Living Outside Massachusetts

Out-of-Network (Unauthorized)

In-Network (Authorized)

Out-of-Network (Unauthorized)

How Benefits are Provided

Care must be provided or authorized by your primary care physician (PCP) chosen from within
your Plans network.

Care must be provided or authorized by your primary care physician (PCP)

chosen from within your plans network.

Care is received from non-participating provider and/or without an

authorization from your PCP.

Care must be provided by a participating provider in order Care is received from non-participating provider.
to receive in-network level of benefits.

Calendar Year Deductible

None

None

$750 individual coverage/$2,500 family coverage. Once the deductible is

met, POS pays 80% of usual, customary and reasonable (UCR) 3 covered
charges until annual out-of-pocket maximum (see below).

None

$750 individual coverage/$2,500 family coverage. Once

the deductible is met, PPO pays 80% of UCR 3 covered
charges until out-of-pocket maximum (see below).

Out-of-Pocket Annual Maximum

$2,000 individual/$6,000 family. (Prescription drug costs do not count toward out-of-pocket maximum.)

$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.

$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 out-of-pocket maximum is met, PPO pays
100% of UCR 3 covered charges.

General Hospital Inpatient

Room and board and hospital services

100%

100%

80% of usual, customary and reasonable charges (UCR)3

100%

80% of usual, customary and reasonable charges (UCR)3

General Hospital Outpatient

100%

100%

80% of UCR

100%

80% of UCR

Lab and X-Ray

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

Non-preventive office visits

$20 copayment

$20 copayment

80% of UCR

$20 copayment

80% of UCR

Vision screening for eyeglasses

100% (one exam per year)

100% (one exam per year)

80% of UCR (one exam per year)

100% (one exam per year)

80% of UCR (one exam per year)

Mental Health

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 80% of UCR

Outpatient - 80% of UCR, deductible does not apply

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 80% of UCR

Outpatient - 80% of UCR, deductible does not apply

Substance Abuse

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 80% of UCR

Outpatient - 80% of UCR, deductible does not apply

Inpatient - 100%
Outpatient - $20 copayment

Inpatient - 80% of UCR

Outpatient - 80% of UCR, deductible does not apply

Maternity

100%

100%

80% of UCR

100%

80% of UCR

Emergency Care

$75 copayment (waived if admitted)

$75 copayment (waived if admitted)

$75 copayment (waived if admitted)

$75 copayment (waived if admitted)

$75 copayment (waived if admitted)

Prescription Drugs through Express

Scripts, 30-day supply retail

$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

Member must submit receipt and will be reimbursed minus

applicable copayment for 30-day prescription at in-network cost

$7 copayment for generic, $20 for preferred brand, $45

for non-preferred brand at a participating pharmacy

Member must submit receipt and will be reimbursed

minus applicable copayment for 30-day prescription at
in-network cost

Prescription Drugs through Express

Scripts, Up to a 90-day supply mail order

$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

$20 copayment (60 visits per calendar year)

$20 copayment (60 visits per calendar year)2

80% of UCR (60 visits per calendar year)2

$20 copayment (60 visits per calendar year)2

80% of UCR (60 visits per calendar year)2

Chiropractic Care

$20 copayment (18 visits per calendar year)

$20 copayment (18 visits per calendar year)

80% of UCR (18 visits per calendar year)

$20 copayment (18 visits per calendar year)

80% of UCR (18 visits per calendar year)2

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

Which Company Offers

Each Plan Type?

Harvard University Group Health

Plan (HUGHP) HMO
617-495-2008 hughp.harvard.edu

Harvard Pilgrim Health Care HMO

888-333-4742
www.harvardpilgrim.org

Harvard University Group Health Plan (HUGHP) POS

617-495-2008
hughp.harvard.edu

Spouse, same-sex or opposite sex domestic partner, and children under age 26

Harvard Pilgrim Health Care (HPHC) POS

888-333-4742
www.harvardpilgrim.org

Harvard Pilgrim Health Care (HPHC) PPO

888-333-4742
www.harvardpilgrim.org

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.

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.

List of in-network providers available by contacting Harvard Pilgrim Health Care.

Access to Harvard University Health

Services (HUHS) Urgent Care

$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. 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

Access to HUHS Pharmacy to fill prescriptions up to

90 days in-person (HUHS physician prescription only).

Access to HUHS Pharmacy to fill prescriptions up to 90 days in-person (HUHS

physician prescription only).

Preventive services include

those as defined by the
Patient Protection and
Affordable Care Act (PPACA);
contact your medical plan
directly for a list of included
services. Preventive services
must be received in-network in
order to be covered in full.

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.

The visit limits on the POS

and PPO are combined for both
in-and-out-of-network services.

Usual, customary and

reasonable (UCR) is an amount
consistent with the normal
range of charges by health care
providers for the same or similar
products or services in the
geographical area where product
or service was provided to
member. You may be responsible
for the balance if claim is for
more than UCR.

This chart applies to faculty,

non-union staff members, and
members of ATC, SEIU, HUPA
and HUSPMGU. This chart has
been designed to acquaint
you with the features of
medical coverage and every
attempt has been made to
summarize these programs
accurately. The actual provisions
of each coverage will govern
if there is any inconsistency
between this chart and Harvards
formal contracts. Contact the
specific health care provider for
detailed coverage questions.