Harvard Pilgrim Forms

Integrated Statistics Health Plans 2020-21

Integrated Statistics offers two Harvard Pilgrim Plans.

The HMO plan is for residents of CT, MA, ME, and RI.

The PPO plan is for residents of other states, or for anyone who prefers a PPO.

You will find descriptions of both plans below. You may choose either plan.

This information applies to both plans:

Federal Notice: Marketplace Coverage Options
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP): Potential help with paying health insurance premiums for children.
Reduce the cost of services: Pay less in out-of-pocket expenses for procedures and tests.
Well-being Program: Earn rewards and reimbursements.
OptumRx Pharmacy Services Transition Frequently Asked Questions for Members.
OptumRx Home Delivery Order Form
Download Waiver of Coverage form: complete this form if you don't need coverage from Integrated Statistics.
Download Section 125 Premium Only Plan Election Form Each year or when you sign up, we also need new Schedule As from everyone to comply with the Section 125 cafeteria plan regulations set forth by the IRS. Please send in this form when you are signing up.
Download the sign-up form

HMO plan

If you choose the HMO, please put a Primary Care Physician (PCP) on the form. You have to have a PCP on the form or I cannot get you signed up. If you do not have a PCP yet, you can still put one on the form and change it later when you do have one.

Summary of benefits and coverage for HMO
Detailed schedule of benefits for HMO

PPO Plan

Summary of benefits and coverage for PPO
Detailed schedule of benefits and coverage for PPO