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NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care
Health Insurance Plan Details (2026 Plan)
by Harvard Pilgrim Health Care of NE
Monthly Premium
HMO
$ubsidy
Gold
- Deductible
- N/A /yr
- Max Out-of-Pocket
- N/A /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $8,700 /yr |
| Max Out-of-Pocket (per family) | $17,400 /yr |
| Plan Type | HMO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $25 Copay |
| Specialist Visit | $50 Copay |
| Emergency Room | 25.00% Coinsurance |
| Inpatient Facility | 25.00% Coinsurance |
| Inpatient Physician | 25.00% Coinsurance |
| Generic Drugs | $10 Copay |
| Preferred Brand Drugs | $60 Copay after deductible |
| Non-preferred Brand Drugs | 35.00% Coinsurance after deductible |
| Specialty Drugs | 45.00% Coinsurance after deductible |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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