New Hampshire health plan · 2026

NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care · 59025NH0370103

Harvard Pilgrim Healthcare, Inc. offers this marketplace health insurance plan (Plan ID 59025NH0370103) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: HMO CSR: Limited Cost Sharing Plan Variation Issuer: Harvard Pilgrim Healthcare, Inc.
Telehealth Data pending HSA eligible No Dental Not listed Vision Adult/Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 78.27%. Expect to pay roughly 21.73% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 79.23% (20.77% member share on average). Learn about AV methodology.

2026 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$428 – $1680

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$8,700

$17400 per group

Review MOOP rules

Office visits

Primary care $25.00
Specialist $50.00
HSA Not eligible

Drug tiers

Generic $10.00
Preferred brand $60.00 Copay after deductible

View formulary tiers

$587 / mo before subsidies

≈ $7042 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1860 / mo before subsidies

≈ $22314 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2252 / mo before subsidies

≈ $27024 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1431 / mo before subsidies

≈ $17174 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

25.00%

Durable Medical Equipment

25.00%

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Enrollment guidance

Stay on top of 2026 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2026 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in New Hampshire). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Limited Cost Sharing Plan Variation plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge, No Charge

Emergency Room Services

25.00%

Durable Medical Equipment

25.00%

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 59025NH0370103
Coverage year 2026
State New Hampshire
Issuer Harvard Pilgrim Healthcare, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 59025NH0370103-03
Available variants

Standard Off Exchange Plan · 59025NH0370103-00

Standard On Exchange Plan · 59025NH0370103-01

Open to Indians below 300% FPL · 59025NH0370103-02

Open to Indians above 300% FPL · 59025NH0370103-03
Last plan update Wed, 15 Oct 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in New Hampshire 4751
PCPs in New Hampshire 645
Telehealth support Data pending
Nationwide providers 23180
4,751 doctors statewide 645 PCPs 23 OB/GYN

Provider network(s)

Providers New Hampshire All US states
All 4751 23180
PCP 645 979
Allergy 5 5
OB/GYN 23 44
Dentists 12 16

Drug coverage overview

3,983 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 1,947
NON-PREFERRED-GENERIC-PREFERRED-BRAND 871
NON-PREFERRED-BRAND 523
NON-PREFERRED-BRAND-SPECIALTY-DRUGS 362
MEDICAL-SERVICE-DRUGS 280
Prior authorization Drugs
Required 811
Not Required 3,172
Step therapy Drugs
Required 38
Not Required 3,945
Quantity limits Drugs
Has Limit 582
No Limit 3,401

Customer highlights

What stands out for members

  • Issuer: Harvard Pilgrim Healthcare, Inc. · Plan ID 59025NH0370103 · 2026 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 59025NH0370103-03 (Open to Indians above 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

There is no visit limit for Chiropractic Care, however member cost sharing applies.

Diabetes Care Management

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Diabetes Education

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

The Plan covers outpatient self-management education and training for the treatment of diabetes, including medical nutrition therapy services, used to diagnose or treat insulin-dependent diabetes, non-insulin dependent diabetes, or gestational diabetes. Services must be provided on an individual basis and be provided by a Plan Provider

Home Health Care Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Laboratory Outpatient and Professional Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their lab services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Other Practitioner Office Visit (Nurse, Physician Assistant)

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Preventive Care/Screening/Immunization

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Certain preventive services as defined in Federal law are covered with no Out-Of-Pocket cost to member when provided by a Plan Provider.

Primary Care Visit to Treat an Injury or Illness

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Rehabilitative Occupational and Rehabilitative Physical Therapy

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined limit of 60 visits per year.\nVisits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Rehabilitative Speech Therapy

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year.\nVisits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Specialist Visit

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Urgent Care Centers or Facilities

$35.00
Tier 1 in-network $35.00
Out-of-network 100.00%

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information. Urgent care centers can be both freestanding and hospital-based. Receiving care from freestanding urgent care clinics often has lower member out of pocket cost. To locate freestanding urgent care clinics in our network, search for 'Urgent Care Center' provider type in the online provider directory.

X-rays and Diagnostic Imaging

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Bone Marrow Transplant

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Chemotherapy

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Delivery and All Inpatient Services for Maternity Care

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

48 Hour Minimum Stay-Vaginal; 96 Hour Minimum Stay-Cesarean.

Dialysis

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Plan approval required for dialysis services when temporarily traveling outside of the state where you live. Such coverage is only provided for up to 30 days per calendar year.

Durable Medical Equipment

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

One breast pump per birth (rented or purchased)

Emergency Room Services

25.00%
Tier 1 in-network 25.00%
Out-of-network 25.00%

Emergency room copayments are waived when a member is directly admitted to the hospital.

Emergency Transportation/Ambulance

25.00%
Tier 1 in-network 25.00%
Out-of-network 25.00%

If you have a Medical Emergency, your Plan covers ambulance transport to the nearest Hospital that can provide care.

Hospice Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospice-Outpatient setting.

Inpatient Hospital Services (e.g., Hospital Stay)

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Inpatient Physician and Surgical Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Inpatient Rehabilitation Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 100.0 Days per Year

Mental/Behavioral Health Inpatient Services

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Mental/Behavioral Health Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Outpatient Rehabilitation Services

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year.\nVisits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Outpatient Surgery Physician/Surgical Services

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Radiation

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Skilled Nursing Facility

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 100.0 Days per Year

Coverage limited to 100 days per year. Custodial or Long Term Care is not covered.

Substance Abuse Disorder Inpatient Services

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Substance Abuse Disorder Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Transplant

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Hearing Aids

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Coverage is limited to 1 hearing aid per hearing-impaired ear when medically necessary.

Major Dental Care - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Prenatal and Postnatal Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Routine Prenatal and Postnatal Care are covered in full.

Routine Eye Exam for Children

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

Members under the age of 19 are covered for one routine eye exam every year.

Well Baby Visits and Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$10.00
Tier 1 in-network $10.00
Out-of-network 100.00%

Certain preventative services are covered at no cost to the member. See a complete list at harvardpilgrim.org\nCoverage for some generic OTC medications is available at tier 1 Rx cost sharing. You can use the drug lookup took at harvardpilgrim.com/rx to search the formulary for OTC medications you may be taking. \n Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.

Non-Preferred Brand Drugs

35.00% Coinsurance after deductible
Tier 1 in-network 35.00% Coinsurance after deductible
Out-of-network 100.00%

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Off Label Prescription Drugs

35.00% Coinsurance after deductible
Tier 1 in-network 35.00% Coinsurance after deductible
Out-of-network 100.00%

Preferred Brand Drugs

$60.00 Copay after deductible
Tier 1 in-network $60.00 Copay after deductible
Out-of-network 100.00%

Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.

Specialty Drugs

45.00% Coinsurance after deductible
Tier 1 in-network 45.00% Coinsurance after deductible
Out-of-network 100.00%

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Coverage for treatment resulting from accidental injury to sound natural teeth and gums. Repairs to teeth with damage resulting from normal activities of daily living or extraordinary use of the teeth is not covered.

Basic Dental Care - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Dental Anesthesia

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Dental Check-Up for Children

Coverage details pending

Coverage is not provided for pediatric dental care.

Infusion Therapy

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Major Dental Care - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Nutritional Counseling

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Orthodontia - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Orthodontia - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Prosthetic Devices

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Coveage is provided for (a) the least costly prosthetic device adequate to allow you to perform Activities of Daily Living. Activities of Daily Living do not include special functions needed for occupational purposes or sports; and (b) one item of each type of prosthetic device. No back-up items or items that serve a duplicate purpose are covered.

Routine Dental Services (Adult)

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Weight Loss Programs

Coverage details pending

There is no coverage for weight loss programs.\n\nMembers can get reimbursement for a fitness club membership or virtual fitness class subscription. Learn more by visiting harvardpilgrim.org/fitnessreimbursement.\n\nThrough our partner, WebMD, program members can earn rewards for participating in a variety of informative and interactive activities that supports all aspects of well-being, including healthy eating, physical activity, financial wellness, mindfulness and meditation, self-care and stress management This program is a subscriber-only program and participants can earn up to $120 in rewards per year.

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

Coverage is not provided for abortion, except when the life of the mother is endangered or when the pregnancy is a result of rape or incest.

Acupuncture

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

There is no visit limit for Acupuncture, however member cost sharing applies.

Allergy Testing

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Applied Behavior Analysis Based Therapies

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Bariatric Surgery

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

In order to receive coverage for bariatric surgery, care must be received from a designated center of excellence. To verify a provider's status, refer to the online provider directory.

Convenience Care Clinic

$25.00
Tier 1 in-network $25.00
Out-of-network 100.00%

Cosmetic Surgery

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Early Intervention Services

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Limit: 40.0 Visit(s) per Year

For Members under the age of 3, coverage is available for services rendered by occupational therapists, physical therapists, speech-language pathologists and clinical social workers

Eye Glasses for Children

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00%

Limit: 1.0 Item(s) per Year

Each dependent under the age of 19 is covered every 12 months for either (a) 1 pair of standard or basic eyeglass frames and lenses or (b) contact lenses. Limits apply, refer to the Schedule of Benefits.

Gender Affirming Care

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Habilitation Services

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year.\nVisits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Imaging (CT/PET Scans, MRIs)

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Infertility Treatment

Coverage details pending

Covered benefits include consultation, evaluation and laboratory testing. Coverage is also provided for services to treat underlying medical conditions that may cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).\n\nInfertility drugs and treatment such as therapeutic donor insemination and advanced reproductive technologies are excluded from coverage.

Inherited Metabolic Disorders - PKU

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Long-Term/Custodial Nursing Home Care

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Low Protein Foods

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Private-Duty Nursing

Coverage details pending

Issuer did not share extra notes for this benefit beyond the summary above.

Reconstructive Surgery

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Routine Eye Exam (Adult)

$25.00
Tier 1 in-network $25.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Exam(s) per 2 Years

Adults are covered for one routine eye exam every 2 years.

Routine Foot Care

$50.00
Tier 1 in-network $50.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Excluded, except for preventive foot care for members with diabetes or systemic circulatory diseases.

Treatment for Temporomandibular Joint Disorders

25.00%
Tier 1 in-network 25.00%
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Surgery-Outpatient setting.

Exclusions: No dental care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.

Wigs

25.00%
Tier 1 in-network 25.00%
Out-of-network 100.00%

Variant attributes

NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care · Variant 59025NH0370103-03

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2026

CSR Variation Type

Limited Cost Sharing Plan Variation

HIOS Product ID

59025NH037

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

59025NH0370103-03

Plan Marketing Name

NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care

Plan Variant Marketing Name

NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

78.27%

Issuer ID

59025

Issuer Marketplace Marketing Name

Harvard Pilgrim Health Care

Market Coverage

Individual

Multiple In Network Tiers

Yes

National Network

No

Network ID

NHN001

Out of Country Coverage

No

Out of Service Area Coverage

No

Service Area ID

NHS001

State Code

NH

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.7922562712883431

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

45.00%

Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

45.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

25.00%

Medical EHB Deductible, In Network (Tier 2), Default Coinsurance

40.00%

SBC Scenario, Having a Baby, Coinsurance

$3,100

SBC Scenario, Having a Baby, Copayment

$60

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$30

SBC Scenario, Having Diabetes, Copayment

$800

SBC Scenario, Having Diabetes, Deductible

$1,000

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$600

SBC Scenario, Treatment of a Simple Fracture, Copayment

$300

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

Not Applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$17400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$8700 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$8,700

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group

$17400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person

$8700 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual

$8,700

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NHF008

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$0

SBC Scenario, Having Diabetes, Limit

$0

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Group

$4000 per group

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$2000 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$2,000

Drug EHB Deductible, In Network (Tier 2), Family Per Group

$4000 per group

Drug EHB Deductible, In Network (Tier 2), Family Per Person

$2000 per person

Drug EHB Deductible, In Network (Tier 2), Individual

$2,000

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

0.997207818

First Tier Utilization

70%

Import Date

10/15/2025

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

Yes

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$0

Medical EHB Deductible, In Network (Tier 2), Family Per Group

$6000 per group

Medical EHB Deductible, In Network (Tier 2), Family Per Person

$3000 per person

Medical EHB Deductible, In Network (Tier 2), Individual

$3,000

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

1/1/2026

Plan Expiration Date

12/31/2026

Plan Type

HMO

QHP/Non QHP

Both

Second Tier Utilization

30%

Source Name

SERFF

Specialist Requiring a Referral

A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.

Plan ID

59025NH0370103

Unique Plan Design

Yes

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in New Hampshire?

NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care (59025NH0370103) is a Gold HMO from Harvard Pilgrim Healthcare, Inc. in New Hampshire for the 2026 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Adult, Child.

Does NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care?

No, out-of-country services are not covered for this plan.

Does NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care cover care outside the service area?

No, the issuer indicates out-of-service-area care is not covered except for emergencies.

How do I enroll in or manage payments for NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care?

Use the issuer portal https://www.harvardpilgrim.org/CMSInitialPaymentPG to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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