Ground ambulance Durable Medical Equipment 5

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1 Washoe County Custom HMO Rx - 7/30/50 Summary of Benefits Type of Service Calendar Year Deductible (CYD) 1 Out-of-Pocket Maximum 2 - Deductibles, coinsurance and copays all accrue toward the out-of-pocket maximum. With respect to family plans, an individual is only subject to the individual out-of-pocket maximum amount. When two family members have each satisfied their individual out-of-pocket maximum amount, then the family out-of-pocket amount is met. Physician Office Visits Telemedicine services Primary care practitioner (PCP) 3 Specialist office visit 4 In-office surgical procedure In-office injectable (excluding specialty drugs) Other services or procedures in the physician s office may incur additional cost(s) as specified in this summary of benefits. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per calendar year. Ambulance Services - Medically necessary only. Air ambulance Ground ambulance Durable Medical Equipment 5 Rental Items approved for purchase Emergency Care - Includes surgeon and physician costs. Emergency room - The copay is waived when the member is admitted as an inpatient directly from the emergency room. If you receive services from an out-of-network provider, you may be responsible for paying the difference between the billed charges and the plan s allowable amount. The plan s allowable amount is the amount the plan would have paid to an in-network provider. Urgent care - In and 0ut-of-area urgent care services are covered for medically necessary covered services. Members should call Prominence Health Plan Member Services for assistance prior to obtaining out-of-area urgent care services. Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Home Health Care - Includes private-duty nursing. Hospice Care Your Out-of-Pocket Expense $0 Single/$0 Family $3,500 Single / $7,000 Family $0 copay per visit 20% coinsurance $200 copay per trip $100 copay per trip $0 copay per item $0 copay per item $250 copay per visit $40 copay per visit Hospital/Outpatient/Ambulatory Services 6 - *Includes surgeon, facility and anesthesia charges Inpatient Outpatient surgery Observation* - No additional copay if transferred from outpatient surgery. Inpatient skilled nursing - Limited to 100 days per calendar year. Acute rehabilitation - Limited to 60 visits per condition per member per calendar year. Rev: 06/22/18 Page 1

2 Summary of Benefits Washoe County Custom HMO Rx - 7/30/50 Type of Service Infusion Therapy* Performed and billed by a hospital outpatient facility * In-network Specialty drugs incur 20% Coinsurance. Kidney Dialysis Services - Covered to the extent not covered by Medicare. Laboratory and Pathology Services Laboratory Pathology Mastectomy Reconstructive Services Inpatient surgery Outpatient surgery Maternity Physician: prenatal care and delivery Delivery room and well-baby hospital care Ancillary maternity charges - including but not limited to fetal non-stress tests and amniocentesis Medical Nutrition Therapy Counseling - Limited to 25 visits per calendar year. Mental Health Services Severe Mental Illness Inpatient Day treatment program Outpatient Outpatient office visit General Mental Health Outpatient office visit Alcohol and Drug Abuse Services Inpatient withdrawal Inpatient rehabilitation Outpatient rehabilitation/day treatment Outpatient office visit Morbid Obesity - Includes inpatient or outpatient services. Bariatric Gastric Restrictive surgery. One procedure every three years; includes surgical complications. Nutritional Supplements - Enteral Therapy and Parenteral Nutrition. Maximum 120 days supply for special food products. Organ Transplants Ostomy Supplies Page 2 Your Out-of-Pocket Expense per admit $1,000 copay $0 copay per delivery $25 copay per visit per admit per 30 day supply per 30 day supply

3 Washoe County Custom HMO Rx - 7/30/50 Summary of Benefits Type of Service Preventive Services 7 - For a complete list of covered services, visit Colorectal cancer screening, colonoscopy, sigmoidoscopy, or fecal occult blood test Mammograms - baseline and annual Pap and pelvic exams Periodic health assessments for hearing and vision for ages 19 and under BRCA genetic counseling and testing services Prenatal well visits Prostate screenings Well baby and child visits, immunizations/vaccinations for children through age 17 Preventive sterilization Prosthetics and Orthotics Prosthetics and orthotics - Foot orthotics limited to one pair per member per calendar year. Dental/oral orthotic appliances, TMJ and/or sleep apnea Limited to one appliance per member per calendar year. Radiation Oncology Therapy Specialist office visit Hospital outpatient therapy facility fee Radiology and Diagnostic Services 8 Routine X-ray and Routine Diagnostic Tests Performed in and billed by a hospital outpatient facility CT SCAN and MRI Performed and billed by a hospital outpatient facility Complex Diagnostic Testing Performed and billed by a hospital outpatient facility Spinal Manipulation - Includes all covered services related to the spinal manipulation. Temporomandibular Joint Dysfunction TMJ surgery - inpatient hospital TMJ non-surgical outpatient office visit Therapies Physical, Occupational and speech - Limited to 90 visits per condition per member per calendar year Autism spectrum disorders - Up to 750 hours per member per calendar year. Your Out-of-Pocket Expense per item $50 copay per item $1,000 copay Page 3

4 Summary of Benefits Washoe County Custom HMO Rx - 7/30/50 Prescription Coverage In-network Pharmacy FDA-approved formulary preventive medications, including female oral contraceptives Generic Preferred brand Non-preferred brand Specialty drugs PharmacyPlus PharmacyPlus generic PharmacyPlus brand Your Out-of-Pocket Expense $0 copay $7 copay $50 copay 20% Coinsurance $2 copay $25 copay Members have the option to fill certain available prescriptions at PharmacyPlus locations for a discounted copay amount. For a complete list of PharmacyPlus locations, please refer to the provider directory. Provider directories can be found online at. Diabetic supplies obtainable from a pharmacy (including: needles, syringes, test strips, lancets and alcohol swabs) available at retail or mail order. The Evidence of Coverage (EOC) sets forth in detail the rights and obligations of both you and the insurance company. It is important you review the EOC once you are enrolled. This disclosure statement provides only a brief description of some important features and limitations of your policy. If you have questions about this summary of benefits (SOB), please call Prominence Health Plan Customer Service at , or (TTY Operator Assistance) Our website,, also serves as an important resource and includes information about provider directories, urgent care and emergency care locations and more. Except for an emergency, all health care services must be coordinated and obtained by a primary care practitioner (PCP) unless otherwise authorized. Prior authorization is the standard process of receiving approval for certain procedures and medical services to ensure that the requested medical care is appropriate and necessary. Not all services require a prior authorization from Prominence Health Plan. Your PCP (or specialist) obtains this on your behalf. For a complete list of services that require prior authorization, please visit or call to confirm if prior authorization has been obtained if required. 1. Deductible - a set amount of covered charges occurring each calendar year which must be paid by the member before benefits are payable under this plan. Copays do not count towards the deductible. 2. Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for nonemergency conditions cannot be used to satisfy the out-of-pocket maximum. 3. Each member must choose a PCP who is responsible to provide, arrange and coordinate all of the health care services to assure continuity of care for you, and to initiate prior authorizations for specialized care you may require. 4. Members may be required to obtain a primary care practitioner (PCP) referral to see a specialist. 5. Durable medical equipment (DME) is covered when medically necessary, authorized by Prominence Health Plan and is in accordance with Medicare DME guidelines. 6. Ambulatory and day-surgery services performed in hospital or other facility. Page 4

5 Washoe County Custom HMO Rx - 7/30/50 Summary of Benefits 7. Some services listed may be billed as diagnostic procedures, not preventive/screening procedures, which could require a member to pay the share of cost as listed under Radiology and Diagnostic Services. Diagnostic procedures are usually conducted when a member has already been diagnosed with an illness or disease, or a member is receiving follow-up treatment for an existing medical condition. In addition, a member share of cost might be incurred if additional procedures that are not listed on the Preventive Services list are conducted concurrently to the preventive service. 8. Some invasive diagnostic procedures are treated as outpatient hospital visits. Choosing your primary care practitioner (PCP) As a HMO member, you must select a primary care practitioner (PCP) to manage all of your medical care. If you have already selected a PCP, his or her name and contact number will appear on your member ID card. If Call for PCP is printed on your ID card, you must select a PCP by following the instructions below. How to select or change your PCP 1.Call Customer Service at or (8 a.m. - 5 p.m. Pacific Time, Monday- Friday) Access to pediatricians For children, you may designate a pediatrician as the primary care practitioner. Access to OB/GYN physicians You do not need prior authorization from or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Customer Serviceat and Rescissions will not rescind coverage once a member is enrolled unless the individual (or a person seeking coverage on behalf of the individual) performs an intentional act, practice or omission that constitutes fraud, or unless the individual makes an intentional material misrepresentation of fact, as prohibited by the terms of the Evidence of Coverage. Prominence HealthFirst will provide at least 30 days advance written notice to each participant who would be affected before coverage will be rescinded. Emergency Services are provided as follows: a. Without prior authorization requirement, even for out-of-network services; b. Without regard to whether the provider of the services is in-network; c. If the services are out-of-network, without any administrative requirements or coverage limitations that are more restrictive than those imposed on in-network services; and d. Without regard to any other tem or condition of the coverage other than: (1) the exclusion of or coordination of benefits; (2) an affiliation or waiting period permitted under ERISA, the PHSA, or the Internal Revenue Code; or (3) applicable cost sharing. Page 5

6 Summary of Benefits Washoe County Custom HMO Rx - 7/30/50 Language Translation Services If you or someone you are assisting has questions about your health benefits or other information related to your plan coverage, you have the right to receive help and information in a language other than English at no cost. Please call Prominence Health Plan Customer Service at the phone number on the back of your member ID card and they can assist you with access to language translation services. You can also contact Customer Service to ask for the translation of written benefit materials. TTY/TDD services are available by dialing Notice of Privacy Practices Member privacy and security are important to Prominence Health Plan. For comprehensive information about how we protect your personal health information (PHI) and how it may be disclosed, refer to the Evidence of Coverage (EOC). You can access the EOC online at or call Customer Service and a copy can be mailed to you. Page 6