2014 MyHPN HMO Plans MyHPN Bronze 1 MyHPN Bronze 2 MyHPN Bronze 3 MyHPN Bronze 4 HPN MiPlanBien Bronce MyHPN Gold 1 MyHPN Gold 2 MyHPN Gold 3 MyHPN Platinum 1 MyHPN Catastrophic Plan Calendar Year Deductible (CYD) Plan Provider $5,000 of EME* per Member $10,000 of EME per Family $6,000 of EME per Member $12,000 of EME per Family $4,750 of EME per Member $9,500 of EME per Family $4,500 of EME per Member $9,000 of EME per Family $4,750 of EME per Member $9,500 of EME per Family $500 of EME per Member $1,000 of EME per Family $750 of EME per Member $1,500 of EME per Family $1,000 of EME per Member $2,000 of EME per Family $100 of EME per Member $200 of EME per Family $6,250 of EME per Member $12,500 of EME per Family Member pays 20% of EME Member pays 10% of EME Member pays 10% of EME Member pays 10% of EME Member pays 20% of EME Member pays 20% of EME Member pays 20% of EME Member pays 10% of EME 0% CoInsurance After CYD Plan Provider Member pays 10% of EME Out of Pocket Maximum (includes deductible, coinsurance and copayments) Plan Provider $6,250 per Member $12,500 per Family $6,250 per Member $12,500 per Family $6,250 per Member $12,500 per Family $6,250 per Member $12,500 per Family $6,250 per Member $12,500 per Family $6,250 per Member $12,500per Family $6,000 per Member $12,000 per Family $4,000 per Member $8,000 per Family $3,500 per Member $7,000 per Family $6,250 per Member $12,500 per Family $0 $25 $0 $30 $0 $35 $0 $30 $0 $10 $0 $10 $0 $20 $0 $5 $0 $0 Medical Office Visits (In Network) Preventive Care Convenient Care NowClinic (Telemedicine) Physican Extender Physician $0 $15 Specialist $15 $25 $30 35 $30 $10 $10 $20 $5 $0 $15 $25 $25 $35 $25 $40 35 45 $25 $40 $10 $20 $10 $20 $20 $30 $5 $10 $0 $0 $50 $70 $90 90 $90 $40 $40 $70 $10 After CYD, Member pays $0 $35 $50 $35 $50 $35 $50 $35 $50 $20 $20 $20 $20 $20 $20 $10 $20 After CYD, Member pays $0 Diagnotic Services (In Network) Routine Laboratory Routine X-ray $35 $50 Emergency Services (In Network) Urgent Care $75 $75 $75 $75 $75 $35 $35 $35 $25 After CYD, Member pays After CYD, Member After CYD, Member After CYD, Member After CYD, Member After CYD, Member After CYD, Member After CYD, Member After CYD, Member $0 $100 pays 10% of EME pays 20% of EME pays 10% of EME pays 10% of EME pays 10% of EME pays 20% of EME pays 20% of EME pays 20% of EME $750 copay; waived if $750 copay; waived if $750 copay; waived if $750 copay; waived if $750 copay; waived if $300 copay; waived if $300 copay; waived if $300 copay; waived if $150 copay; waived if After CYD, Member pays Emergency Room Visit admitted admitted admitted admitted admitted admitted admitted admitted admitted 0% of EME Ambulance Hospital Services (In Network) In Patient Out Patient After CYD, Insured pays 10% of EME After CYD, Insured pays 20% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Member pays 10% of EME After CYD, Member pays 5% of EME After CYD, Member pays 0% of EME Physician Surgical Services (In Network) Inpatient or Outpatient Facility Ambulatory Surgical Facility Anesthesia After CYD, Insured pays 10% of EME After CYD, Insured pays 20% of EME $75 per surgery $75 per surgery $75 per surgery $75 per surgery $75 per surgery $20 per surgery $25 per surgery $25 per surgery After CYD, Insured pays 10% of EME After CYD, Insured pays 20% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Insured pays 10% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Member pays 20% of EME After CYD, Member After CYD, Member pays $0 pays 10% of EME After CYD, Member pays After CYD, Member pays 5% of EME 0% of EME After CYD, Member pays 10% of EME Prescription Drugs (In Network) Rx Deductble **means after CYD Tier 1 Tier 2 Tier 3 Tier 4 Mail Order $0 Rx Deductible The combined medical & prescription drug calendar year deductible applies to tiers 2, 3 & 4 $25 $50** $75** $250** $25 $50** $75** $250** $25 $25 $50** $50** $75** $75** $250** $250** 2.5 x Tier Copay subject to any CYD $25 $50** $75** $250** $15 $35 $65 $250 $15 $35 $65 $250 2.5 x Tier Copay $0 Rx Deductible $15 $35 $65 $250 $10 $25 $60 $250 2.5 x Tier Copay Tier 1: $0 copay, not subject to CYD; Tiers 2, 3, 4 & Mail Order: $0 After combined medical & Rx drug CYD *EME (Eligible Medical Expenses) means the maximum amount the Plan will pay for a Covered Service in accordance with the Plan Reimbursement Schedule; the Member is responsible for all charges in excess of EME. Non-Plan Provider charges are not covered, other than for Emergency Services. Non-Plan Provider charges may be substantial and do not accrue toward the Calendar Year Out of Pocket Maximum. These Plans include additional benefits, exclusions and limitations which are shown in the Health Plan of Nevada Agreement of Coverage, Attachment A Benefit Schedule, any other applicable Riders and the Summary of Benefit Coverages. Copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments.
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