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Hometown Health / 10352-HTH job name: 11196918 / HTH Commercial BAAG
COMMERCIAL / STATEWIDE
release date: ASAP vendor: Printing Services of Nevada release file type: Hi-Res PDF
finished/trim size: 17” x 11” (non-bleed) colors: 4-color process
Last modified -- 8/11 05:15
10352HTH_1196918_HTH_Statewide_Commercial_BAAG_MECH
HMO plans only available in select northern Nevada counties; out of network benefits not available for HMO plans. CYD indicates you must satisfy the Calendar Year Deductible before benefits are paid by Hometown Health. * Plans that include one (1) free PCP visit are indicated with an asterisk. ** Gym Benefit requires completion of an online Health Risk Assessment each year.
† Gold 500 and Gold 1000 Plans not available to individuals in southern Nevada. †† Catastrophic Plan is only available to individuals. # Platinum Plan is only available to Small Group Plans in Washoe & Carson City.In
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eEffective January 1, 2021 In-Network Benefits
CALENDAR YEAR DEDUCTIBLES (CYD) AND OOPMaxIndividual Medical Deductible $0 $500 $1,000 $2,000 $3,000 $4,000 $4,500 $5,500 $1,400 $8,550 $3,700 $3,500 $7,000 $8,550 $8,550Family Medical Deductible $0 $1,000 $2,000 $4,000 $6,000 $8,000 $9,000 $11,000 $2,800 $17,100 $7,400 $7,000 $14,000 $17,100 $17,100Individual Pharmacy Deductible $0 $0 $0 $0 $0 $0 $0 $0 Combined Combined Combined Combined Combined Combined CombinedFamily Pharmacy Deductible $0 $0 $0 $0 $0 $0 $0 $0 Combined Combined Combined Combined Combined Combined CombinedIndividual Out-of-Pocket Max $4,000 $5,000 $5,500 $6,000 $6,500 $8,000 $8,200 $8,400 $7,000 $8,550 $7,000 $7,000 $7,000 $8,550 $8,550Family Out-of-Pocket Max $8,000 $10,000 $11,000 $12,000 $13,000 $16,000 $16,400 $16,800 $14,000 $17,100 $14,000 $14,000 $14,000 $17,100 $17,100PHYSICIAN OFFICE VISITSVirtual Visit Renown Provider/PCP Office Visit Renown Provider $0 / $0 $0 / $10 $0 / $15 $0 / $20 $0 / $30 $0 / $30 $0 / $35 $0 / $40 $0 / CYD, $10 $0 / $45 $0 / CYD, $10 $0 / CYD, $45 $0 / CYD, $0 $0 / CYD, $0 $50 / $50PCP Office Visits* $10* $30* $35* $40* $50* $50* $55* $60* CYD, $30 $65* CYD, $30 CYD, $70 CYD, $0 CYD, $0* $70, CYD, $70Specialist Care Virtual Visit Renown Provider (HSA Only) N/A N/A N/A N/A N/A N/A N/A N/A $60 N/A $60 100% Member Paid $0 N/A N/ASpecialist Office Visits $40 $60 $70 $80 $100 $100 $110 $120 CYD, $60 $130 CYD, $60 CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0Preventive (ACA Covered) Screenings No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No Cost No CostLAB, IMAGING AND DIAGNOSTICSRoutine Lab Services $10 $45 $50 $50 $50 $50 $55 $60 CYD, $50 $60 CYD, $50 CYD, $55 CYD, $0 CYD, $0 CYD, $0Diagnostic and X-Ray $40 $70 $85 $95 $105 $120 $120 $120 CYD, $75 $120 CYD, $85 CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0Imaging (CT/PET/MRI) $200 $280 $325 $400 $450 $475 $500 CYD, $550 CYD, $450 CYD, $0 CYD, $550 CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0FACILITY/SURGICALInpatient Hospital $1,000 $2,000 $2,500 $3,000 $3,500 $3,500 CYD, 30% CYD, 30% CYD, 30% CYD, $0 CYD, 30% CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0Outpatient Surgical Services $500 $1,000 $1,100 $1,100 $1,200 $1,200 $1,300 $1,400 CYD, $1,200 CYD, $0 CYD, $1,200 CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0EMERGENCY AND URGENT CAREUrgent Care Center Services $70 $70 $80 $90 $100 $100 $100 $100 CYD, $75 $120 CYD, $75 CYD, $120 CYD, $0 CYD, $0 CYD, $0Emergency Room Services $800 $1,000 $1,200 $1,300 $1,500 $1,500 CYD, 30% CYD, 30% CYD, 30% CYD, $0 CYD, 30% CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0Ambulance Services (ground/air/water) $0 CYD, 20% CYD, 20% CYD, 20% CYD, 20% CYD, 30% CYD, 30% CYD, 30% CYD, 30% CYD, $0 CYD, 30% CYD, 100% Member Paid§ CYD, $0 CYD, $0 CYD, $0PRESCRIPTION DRUGS AND DIABETIC SUPPLIESRx - Generic Drugs $4 $10 $10 $15 $15 $20 $20 $20 CYD, $20 $30 CYD, $30 CYD, $30 CYD, $0 CYD, $0 CYD, $0Rx - Preferred Brand Drugs $50 $60 $65 $75 $80 $80 $80 $80 CYD, $85 $105 CYD, $95 CYD, $125 CYD, $0 CYD, $0 CYD, $0Rx - Non-Preferred Brand Drugs $100 $120 $140 $160 $180 $180 $180 $180 CYD, $135 CYD, $0 CYD, $150 CYD, $250 CYD, $0 CYD, $0 CYD, $0Diabetic Supplies - Preferred $50 $60 $65 $75 $80 $80 $80 $80 CYD, $85 $105 CYD, $95 CYD, $125 CYD, $0 CYD, $0 CYD, $0Diabetic Supplies - Non-Preferred $100 $120 $140 $160 $180 $180 $180 $180 CYD, $135 CYD, $0 CYD, $150 CYD, $250 CYD, $0 CYD, $0 CYD, $0Special Pharmaceuticals 20% 20% 20% 20% 20% 30% 30% 30% CYD, 30% CYD, $0 CYD, 30% CYD, 40% Member Paid CYD, $0 CYD, $0 CYD, $0PEDIATRIC COVERAGEPediatric Vision $0 $0 $0 $0 $0 $0 $0 $0 CYD, $0 $0 CYD, $0 CYD, $0 CYD, $0 $0 CYD, $0Healthy Tracks Wellness Program / Gym Benefit** Included Included Included Included Included Included Included Included Included Included Included Included Included Included IncludedDIFFERENCE IN COST FROM GOLD 1000 CO 1.9% 0% 0% -1.6% -4.3% -9% -13.3% -14.3% -16.9% -18.7% -20.1% -25.5% -26.3% -29.7% -33.2%
Gold 500 CO
10-CO 2000 A D0500X2
Gold 1000 CO
15-CO 2500 A D1000X2
Gold 2000 CO
30-CO 3000 A D2000X2
Gold 3000 CO
30-CO 3500 A D3000X2
Silver 4000 CO
30-CO 3500 A D4000X2
Silver 4500 CO
35-70 CINS P D4500X2
Silver 5500 CO
40-70 CINS P D5500X2
Silver 1400 HSA
10-70 CINS U D1400X2 HSA
Bronze 8550 CO
45-NA 0000 P D8550X2
Silver 3700 HSA
10-70 CINS E D3700X2 HSA
Bronze 3500 HSA
45-00 CINS E D3500X2 HSA
Bronze 7000 HSA
00-NA 0000 E D7000X2 HSA
Bronze 8550
00-NA 0000 P D8550X2
CATASTROPHIC 8550 CO
50-NA 0000 P D8550X2
Platinum 0 CO
00-CO 1000 A D0000X2
– SEE DISCLAIMERS BELOW –
Small Group Plan available in all Nevada counties except Elko and White Pine. Individual & Family Plans available in Carson City, Clark, Douglas, Lyon, Story and Washoe counties. National network available only for Small Group PPO members who live and work outside Nevada. §100% paid by member after CYD met until OOPMax is reached. LADD/2008-1196918
Hometown Health / 10352-HTH job name: 11196918 / HTH Commercial BAAG
COMMERCIAL / STATEWIDE
release date: ASAP vendor: Printing Services of Nevada release file type: Hi-Res PDF
finished/trim size: 17” x 11” (non-bleed) colors: 4-color process
Last modified -- 8/11 05:15
10352HTH_1196918_HTH_Statewide_Commercial_BAAG_MECH
Hometown Health partners with DispatchHealth to deliver high-quality medical care to the comfort of members’ homes as a convenient, cost-effective emergency room alternative.
Important things to know:
• DispatchHealth is available from 8 a.m. to 10 p.m. seven days a week, 365 days a year.
• REQUESTING CARE IS EASY! You can use the DispatchHealth mobile app, visit their website at dispatchhealth.com or call them directly at 775-439-1529.
• A DispatchHealth Team arrives within a few hours and consists of either a physicians assistant or nurse practitioner along with a medical technician and an on-call ER physician.
• DispatchHealth will prescribe any prescription medications members might need, update their provider and submit the visit to Hometown Health so members can focus on feeling better, faster.
Healthy Tracks, our health and wellness program, provides many useful tools to help members take control of their health, reduce health risks and help them live a longer, happier life.
Members have access to:
• AGE GAGE: Complete the health assessment and learn your health age
• PERSONAL CHALLENGES: Members have access to sign up for over 200 health challenges to improve their health and reach their goals
• SYNC FITNESS DEVICES: Sync Fitbits, AppleWatchesorotherfitnessdevices to track and log activity
• TEXT TRACKING: Members can sign up for text reminders to keep them on track
• ONLINE UNIVERSITY: Get access to interactive health and wellness workshops and educational videos
EASY TO SIGN UP!Visit the hometownhealth.com website and click on “Healthy Tracks” to register. You will want to have your Hometown Health identificationcardhandy.
Your Home. Your Town. Your Health.
Teladoc is Hometown Health’s preferred partner for virtual visit providers. It is available in all 50 states, 24 hours per day, 7 days per week.
It is a convenient and affordable option for quality care when members are traveling and need care, are considering going to urgent careorneedashort-termprescriptionrefill. Teladoc allows members to talk with a U.S.Boardcertifiedproviderwhocan diagnose, recommend treatment and prescribe medication, when appropriate.
Some of the health issues Teladoc doctors treat include:
• Sinus problems • Bronchitis • Allergies • Cold&flu • Respiratory infection • Ear infection • Sore throat • And more
REGISTERING WITH TELADOC IS EASY! Visit the hometownhealth.com website and click on “Teladoc” for quick access to the Teladoc registration page. You can also call Teladoc at 1-800-Teladoc.
The myHometown Health mobile app givesmembersaccesstotheirbenefit information at the touch of a button. Hometown Health members will have around-the-clock centralized access tobenefits,referrals,providersearch, member ID cards and more! Plus, with fingerprintandfacialrecognitiontechnology,memberscanbeconfidentwiththeirbenefitinformation being safe and secure.
My Benefits Coverage and Mobile App
FOR A FREE COPY OF BENEFITS CONTACT US • hometownhealth.com • 775-982-3232 • 702-914-0863 • 888-775-7003
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