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

18 IF PPO 60-00 CINS U D1350X2 HSA


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Zip Code89110
Applicant8/20/1983 Male
Coverage Start8/21/2018
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Benefits & Coverage

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


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
Diabetes Education
Infusion Therapy
Laboratory Outpatient and Professional Services
Reconstructive Surgery
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
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
PremiumPlan NameDeductible
from $356
18 IF HMO 60-00 CINS U D1350X2 HSA
from $406
18 IF PPO 25-70 CINS U D1350X2 HSA
from $414
18 IF HMO 25-70 CINS U D1350X2 HSA

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