Better understand your plan and how to get the most out of it.
The latest state regulations, and how upcoming changes may affect your coverage:
Massachusetts
The following coverage applies to all fully insured commercial Massachusetts plans.
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS)
Massachusetts law requires commercial health plans provide coverage for PANDAS and PANS. The following services will be covered for children and adolescents effective 1/1/2022.
- Coverage of treatment for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS), including, but not limited to, the use of intravenous immunoglobulin therapy (IVIG).
Please see your benefit handbook for more information. You may also call the Member Services Department at (888) 333-4742, if you have any questions about your benefits or coverage.
Connecticut
The following coverage applies to all fully insured commercial Connecticut plans.
Diabetes
In accordance with PA20‐4, effective 1/1/22, member cost sharing for insulin and noninsulin glucagon
drugs will not exceed $25 per each 30‐day supply. Member cost sharing for diabetes devices (e.g.
syringes, lancets) will not exceed $100 per each 30-day supply.
Dental and vision coverage for dependent children
In accordance with PA21‐149, effective 1/1/22, the maximum eligibility age for pediatric dental and
pediatric vision benefits for small group plans (and pediatric vision benefits, where available, for large
group plans), will increase from 19 to 26.
Maine
The following coverage applies to all fully insured commercial Maine plans.
Access to treatment for serious mental illness
In accordance with new Maine state legislative changes, effective 1/1/2022 Harvard Pilgrim will approve
prior authorization requests for prescribed formulary medications used to assess or treat a member’s
serious mental illness, as defined by the state of Maine. Additionally, serious mental illness may be
used as a reason to override and approve Harvard Pilgrim’s step therapy requirements.
HIV prevention medications
In accordance with new Maine state legislative changes, effective 1/1/2022 Harvard Pilgrim will cover at
least one HIV-preventive therapeutic equivalent medication, if approved by the FDA, at no out‐of-pocket
cost. This applies when the medication is deemed medically necessary by a health plan provider.
Additionally, prior authorization and step therapy requirements will not apply to at least one HIV
prevention medication or therapeutic equivalent in the formulary.
Certified midwives
In accordance with new Maine state legislative changes, effective 1/1/2022 services performed by
certified midwives are covered if such services are covered by other providers.
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Care management programs
Whatever your health concerns, Harvard Pilgrim’s Care Team of registered nurses, clinical social workers and certified health coaches can help you manage your condition, improve your quality of life and support you in reaching your wellness goals through our population health programs and offerings.
Our Care Team offers personalized support. They help members expecting a baby to have the healthiest possible pregnancy. They support members living with multiple or complex conditions, such as chronic kidney disease. They can also help members manage and learn more about specific conditions, such as diabetes, asthma, cancer and heart disease, with care plans customized to address the unique needs of each.
To learn more about these programs and find out if you may be eligible to enroll, log in to your account to send us a confidential email. Or, you can call us at (866) 750-2068.
Care management support is available at no cost to members and is included with Harvard Pilgrim benefits. Our Care Team works as an educational resource to support our members’ health and wellness goals.
At Harvard Pilgrim, our goal is to provide you with detailed plan information to help guide you toward making the very best health care decisions for you and your family. Log in to your account and click on Plan Details and then View My Plan Documents to view, download, save and print benefits and coverage documents — including your benefit handbook.