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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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