2018 18 IF PPO 60-00 CINS U D1350X2 HSA Plan Details - HealthPocket

18 IF PPO 60-00 CINS U D1350X2 HSA

$353.18/mo

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Zip Code89110
Applicant2/17/1984 Male
Coverage Start2/18/2019

Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan Name18 IF PPO 60-00 CINS U D1350X2 HSA
Plan IDhhs-85266NV0030080
Plan Year2018
Insurance Provider
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$1,350
Out-of-Pocket Maximum$6,650
Personal Score

Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$60 Copay after deductible
Specialist Visit$120 Copay after deductible
Laboratory Outpatient and Professional Services$50 Copay after deductible
X-rays and Diagnostic Imaging$100 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans100.00% Coinsurance after deductible
Deductible - Family$2700 per group
Out-of-Pocket Maximum - Family$13300 per group

Prescription drug coverage

Generic Drugs$30 Copay after deductible
Preferred Brand Drugs$80 Copay after deductible
Non-Preferred Brand Drugs60.00% Coinsurance after deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://apps.hometownhealth.com/OnlineProviderDirectory/
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Emergencies and urgent care only outside of Nevada
Does this plan cover services outside the country?Yes - Emergencies Only

Hospital services

Emergency Room Services100.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)100.00% Coinsurance after deductible
Inpatient Physician and Surgical Services100.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service100.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$0 Copay after deductible
Delivery and all inpatient services for maternity care100.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$60 Copay after deductible
Mental/Behavioral Health Inpatient Services100.00% Coinsurance after deductible
Substance use disorder outpatient services$60 Copay after deductible
Substance use disorder inpatient services100.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Acupuncture
Bariatric Surgery
Hearing Aids
Infertility Treatment
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Prosthetic Devices
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
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Ezpeleta, Carlos
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Saab, Ahmad
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Chien, Jerry
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Sataray, Justo
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Sanchez, Francisco
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Milling, Dominique
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Klahn, Logan
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Maufas, Octavia
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Santos, Joseph
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Chapa, Elizabeth
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Wilson, Trenise
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Acosta Vazquez, Kirenia
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Mitzel, Paul
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Garrett, Antoinette
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Sudweeks, Skyler
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Flores, Melissa
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Smith, Michael
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Lewis, Labrina
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Ranson, Dynasty
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Ati Physical Therapy
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Carlos Ezpeleta, M.D.
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  • Phone Number
    (702) 383-6250
  • Office Locations
    61 N. Nellis Blvd.
    Las Vegas, NV 89110
61 N. Nellis Blvd. Las Vegas NV, 89110

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.