How to use your medical plan

Know how your plan works

Each insurance plan has different rules for using health care benefits. You should become familiar with your specific Harvard Pilgrim plan benefits and limitations when you first sign up — especially if the plan requires you to receive your care from certain doctors and hospitals. Your benefits, costs and limits are outlined in the Schedule of Benefits and your Benefit Handbook.

The Schedule of Benefits (SOB) is a summary of benefits covered under your health insurance plan, along with the associated costs and service limits. SOBs outline which services and treatments are covered and which are not. You'll find your SOB with your Plan Documents.

Your Benefit Handbook works together with the SOB and provides more detail on your covered benefits and services, as well as any exclusions. You'll also find your Benefit Handbook with your Plan Documents.

Understand your plan's referral rules

Many HMO plans require a referral from your primary care provider (PCP) for specialist visits. If you have a POS plan, referrals are required for specialty care for services to be covered at the in-network (lower-cost) benefit level. PPO plans don't require referrals for specialty care services.

If you need to see a specialist and your plan requires a referral, you must contact your PCP for the referral before your appointment with the specialist. In most cases, your PCP will give you a referral to a specialist who's affiliated with the same hospital as your PCP or who has a working relationship with their practice.

Choose a PCP

Individuals with health insurance typically have a PCP who oversees their medical care. A PCP may be a physician, physician assistant or a nurse practitioner specializing in:

• Internal medicine
• Adult medicine
• Adolescent medicine
• Geriatric medicine
• Pediatrics
• Family practice

Check that your PCP is in your plan's network and listed in your member profile before making an appointment. You can change your PCP through your member account or by calling Member Services at 888-333-4742 (TTY: 711). If you don’t already have a PCP, or if your current provider is not part of your plan's network, review our tips for choosing a PCP for helpful information on finding the right provider.

Use our provider directory to find in-network providers

The provider directory includes PCPs, specialists, hospitals and other providers that are in your plan's network. You can search for providers by state and town, specialty and languages spoken. Be sure that you’re logged in to your secure member account to get results for your plan quickly and easily.

If you have a limited network or tiered network plan (which will be stated in your Schedule of Benefits), its provider directory will list only those providers who participate in the plan's network.

Your plan may include different cost sharing options based on the location where you receive medical services. It’s important for you to know the out-of-pocket costs that different service locations may have (e.g., hospital vs. physician’s office) before deciding with your PCP where to get treatment. Find details about your plan and how it works in your SOB and Benefit Handbook.

Become familiar with your urgent care options

If you have an injury or illness that isn't life-threatening, and your PCP’s office is closed, urgent care options can help you save time and money and avoid the emergency room (ER). These options include:

• Doctor On Demand (virtual visits)
• Retail clinics
• Urgent care centers

Learn about ways to save money

Your Harvard Pilgrim membership can help you save money on a variety of products and services, including:

• Dental care
• Family and senior care
• Fitness programs
• Healthy eating
• Hearing aids
• Holistic wellness
• Programs to help you quit smoking
• Vision care

Learn about Discounts & Savings.