Summary of Benefits. HMO Beyond 1A Premier North. Prominence HealthFirst Small Group Health Plan. $500 single/ 3x family

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1 HMO Beyond 1A Premier North Summary of Benefits Calendar Year Deductible (CYD) 1 Coinsurance Applies to outpatient facility and outpatient surgery physician/surgical services. Default Coinsurance for other covered services. Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue towards the out-of-pocket maximum. 2 Physician Office Visits Telemedicine services Primary care practitioner (PCP) 3 Specialist office visit - may require prior authorization 4 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 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 outof-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 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 Health Care - Includes private-duty nursing; maximum 30 visits per calendar year. 6XHMB1APNSG Rev: 09/28/15 $500 single/ 3x family 20% coinsurance $2,500 single/ 2x family $5 copay 20% coinsurance per trip 20% coinsurance per trip $200 copay per visit $50 copay per visit Page 1

2 Summary of Benefits HMO Beyond 1A Premier North Hospice Care Hospice care Respite inpatient - Limited to 10 days per 6 months. Respite outpatient - Limited to 10 visits per year. Bereavement services - Limited to 5 visits per year. 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 $200 copay per delivery Page 2

3 HMO Beyond 1A Premier North Summary of Benefits Mental Health Services (continued) Severe Mental Illness 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 - Per 30 day supply Pediatric Dental - Pediatric Dental Coverage up to Age 19 In-Network Out-of-Network Diagnostic and Preventive Services - Not subject to the Deductible 30% Coinsurance Basic Restorative Procedures - Subject to the Deductible 20% Coinsurance 50% Coinsurance Major Restorative Procedures - Subject to the Deductible 50% Coinsurance 80% Coinsurance Orthodontia 4 - Subject to the Deductible 50% Coinsurance 80% Coinsurance 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. Page 3

4 Summary of Benefits HMO Beyond 1A Premier North 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 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. $25 copay $150 copay $150 copay $100 copay Page 4

5 HMO Beyond 1A Premier North Summary of Benefits Prescription Coverage In-network Pharmacy FDA-approved preventive medications, including female oral contraceptives Generic Preferred brand Non-preferred brand Specialty drugs Your Out-of-Pocket Expense $0 copay $5 copay $15 copay $30 copay 20% coinsurance PharmacyPlus PharmacyPlus generic $0 copay PharmacyPlus brand $10 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 Member Services 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. 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 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 Page 5

6 Summary of Benefits HMO Beyond 1A Premier North 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 or (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. 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 Member Services at 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 6