New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 400 - FILINGS FOR LIFE, ACCIDENT, AND HEALTH INSURANCE
Part Ins 403 - Standard Wellness Plan Rate and Form Filing Standards
Appendix A - NH HealthFirst Program Benefit Summary

Benefits

HealthFirst Plan

Preventive Care Services:

Immunizations, Lead Screenings, PSA, Routine Physical Exams (including family planning, pre-natal & well child care), annual ob-gyn visits (including mammography), Routine Hearing Laboratory and an Annual Care Plan for Chronic Illnesses

Covered in Full

Other Office Visits:

Primary Care Copay

Specialist Copay

Colonoscopy

$20 per visit

$50 per visit

Subject to $250 copay

Deductible (single family traditional)

Coinsurance

Max out of pocket (single/family traditional)

Tier 1 Facilities: $2,500/$5,000

Tier 2 Facilities: $4,000/$8,000

None

$5,000/$10,000

Lifetime Maximum

No maximum

In/Out Patient Hospital Care

Subject to deductible, including diagnostic lab

Skilled Nursing & Rehab Facilities:

SNF limited to 100 days/CY, Rehabilitation Facility limited to 60 days/CY

Subject to deductible

Diagnostic Labs and X-Rays:

Labs

X-Rays

MRI, CT and PET Scans

Covered in full

Subject to deductible

Subject to deductible

Outpatient Surgery:

Doctor's Office

Hospital/Surgical Day Care

$20/$50 per visit

Subject to deductible

Urgent/Emergency Room Care:

Urgent Care Facility Copay

Emergency Room Facility Copay

$100 per visit for the facility charge. All other services are subject to the Tier 1 or Tier 2 deductible.

$200 per visit

Ambulance (medically necessary)

Subject to deductible

Short Term Therapy (PT, OT, ST)

$50 per visit

Chiropractic

Not covered

Mental Health/Substance Abuse Services:

Office Visits

Facility

$20 per visit

Subject to deductible

Durable Medical Equipment:

Limited to $3,000/Mbr/CY

Subject to deductible

Prescription Drugs:

Covered medication, diabetic supplies and contraception devices purchased at a network pharmacy

Certain maintenance drugs are available for a supply greater than 30 days.

Maximum out-of-pocket (single/family traditional)

Important Notes:

If, due to medical necessity, your physician prescribes a brand drug, you pay only the formulary or non-formulary brand copay shown on this summary.

For formulary brand and non-formulary brand at least 2 brand drugs shall be available for each covered benefit therapeutic class.

$10 copay/generic

$35 copay/formulary brand

$50 copay/non-formulary brand

No Max

Copayment applies to each 30 day supply.

$5,000/$10,000

Members are required to work with a care navigator for certain tests and procedures.

Members shall establish a relationship with a primary care provider.

The benefit plan shall additionally cover the following services:

Screening and Brief Intervention for Alcohol and Drug Abuse

Body Mass Index Screening

After-hours care