Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual is only subject to the individual $0 single/ 2x family 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 maximum amount is met. 2 Physician Office Visits Telemedicine services Primary care practitioner (PCP) 3 per visit Specialist office visit - will require prior authorization 4 per visit PCP and specialist copay applies to all services in the practitioner s office unless the service is also listed on this summary of benefits with an additional copay. Alternative Medicine - Homeopathy, acupuncture and integrated medicine. $1,500 maximum per visit per calendar year. Ambulance Services - Medically necessary only. Air ambulance Ground ambulance Durable Medical Equipment 5 Rental Items approved for purchase per trip per trip per item per item Emergency Care - Includes surgeon and physician costs. Emergency room - The copay is waived when the member is admitted as an inpatient directly per visit 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 per visit covered services. Members should call Prominence Health Plan Member Services 844.238.2292 for assistance prior to obtaining out-of-area urgent care services. Health and Wellness Services Online Wellness Assessment - OWA Link: prominencehealthplan.com Telephonic health coaching - Six sessions per condition per calendar year (diabetes management, tobacco cessation and weight management) Hearing Aids - Limited to one every three years. Home Healthcare - Includes private-duty nursing; maximum 30 visits per calendar year. Hospice Care Hospice care Respite inpatient - Limited to 10 per 6 months. Respite outpatient - Limited to 10 visits per year. Bereavement services - Limited to 5 visits per year. 6XHEXAIC per item per visit per visit Page 1
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 (combined with physical occupational and speech therapies); includes outpatient rehabilitation visits. Infertility Treatment Services Office visit evaluation - Please refer to the applicable surgical procedure copay and/or coinsurance amount for any surgical infertility procedures performed. Infusion Therapy* Performed and billed by a physician s office or free-standing, outpatient facility Performed and billed by a hospital outpatient facility * 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 Page 2 per visit per visit per visit per delivery per visit per visit
Mental Health Services (continued) 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 Orthotics - Foot orthotics limited to one pair per year Ostomy Supplies Preventive Services 7 - For a complete list of covered services, visit http://doi.nv.gov/healthcare-reform/individuals-families/preventative-care/ 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 Prosthetic Prosthetic devices 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 and billed by a free-standing, outpatient facility Performed in and billed by a hospital outpatient facility CT SCAN and MRI Performed and billed by a free-standing, outpatient facility Performed and billed by a hospital outpatient facility per 30 day supply per item per item per item per visit Page 3
Radiology and Diagnostic Services 8 (continued) Complex Diagnostic Testing Performed and billed by a free-standing, outpatient facility Performed and billed by a hospital outpatient facility Spinal Manipulation Temporomandibular Joint Dysfunction TMJ surgery - inpatient hospital TMJ non-surgical outpatient office visit Therapies Physical, occupational and speech - Limited to 60 visits per condition per member per calendar year. Habilitative - Limited to 60 visits per condition per member per calendar year. Rehabilitative - Limited to 60 visits per condition per member per calendar year. Autism spectrum disorders - Limited to 200 visits per member per calendar year. Vision - Pediatric - Coverage up to age 19 Eye exam - Limited to one routine eye exam per child per year. Low-vision exam - Limited to one routine eye exam per child per year. Glasses - Limited to one pair of basic frames and lenses. Post-cataract services - Limited to one pair of basic frames and lenses. Prescription Coverage In-network Pharmacy FDA-approved preventive medications, including female oral contraceptives Generic Preferred brand Non-preferred brand Specialty drugs Page 4 per visit per visit per visit per visit per visit per visit per item 0% coinsurance PharmacyPlus PharmacyPlus generic PharmacyPlus brand 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. Eligible American Indians, as determined by the Exchange, are exempt from cost sharing requirements when covered services are rendered by an Indian Health Service (HIS), Indian Tribe, Tribal Organization, or Urban Indian Organization (UIO) or through referall under contract health services. There will be no member responsibility for American Indians when Covered Services are rendered by one of these providers.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 Member Services at 775.770.9314, 844.238.2292 or (TTY Operator Assistance) 800.326.6868. 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. 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. 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 844.238.2292 to confirm if prior authorization has been obtained if required. 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. 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 Member Services at 775.770.9314 or 844.238.2292 (8 a.m. - 5 p.m. Pacific Time, Monday-Friday) 2. Be prepared to indicate your PCP selection to Member Services. You must use your selected PCP to manage your care If you see a primary care practitioner who is not your assigned PCP, your claim(s) may be denied. Always check with your PCP before seeking care from a specialist. Your PCP can help determine if specialty care (i.e., cardiology, gastroenterology, neurology, etc.) is needed. Page 5
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 healthcare professional in our network who specializes in obstetrics or gynecology. TThe healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services or following a pre-approved treatment plan. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, contact Prominence Health Plan Member Services at 775.770.9314 and 844.238.2292. 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 6