Health Plan of Nevada Individual Off Exchange HMO Portfolio Effective Date: January 1, 2015 Plan Name Out of Pocket Maximum PCP Per Member $250 10% $3,500 $500 20% $750 Network Copay SPEC Convenient Care/ Extender NowClinic Routine Lab Routine Urgent X-Ray Care Emergency Room Inpatient Facility O/P Surg Copay Rx Deductible and 4 Tier - at ASC Facility Copays $10 $10 $5 $5 $10 $20 $25 $150 10%* 5%* $10/$25/$60/$250** $6,000 $25 $50 $15 $15 $20 $20 $35 $300 20%* $100* $15/$35/$65/$250** 20% $6,000 $30 $60 $20 $20 $20 $20 $35 $300 20%* $100* $15/$35/$65/$250** $1,000 20% $3,500 $30 $70 $20 $20 $20 $20 $35 $300 20%* $100* $15/$35/$65/$250** $750 20% $4,500 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* $15/$35/$65/$250** $500 20% $3,500 $10 $50 $5 $5 $20 $20 $35 $300 20%* $100* $15/$35/$65/$250** $3,000 30% $6,000 $20 $40 $10 $10 $25 $25 $40 $400 30%* $150* $3,000 30% $6,000 $25 $50 $15 $15 $25 $25 $40 $400 30%* $150* $2,500 30% $6,000 $40 $80 $30 $30 $25 $25 $40 $400 30%* $150* $2,250 20% $6,000 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20%* $2,000 30% $6,600 $15 $65 $5 $5 $25 $25 $40 $400 30%* $150* $5,000 30% $6,600 $15 $65 $5 $5 $25 $25 $40 $400 30%* $150* $5,000 10% $6,000 $25 $50 $15 $15 $35 $50 $75 $750 10%* $200* $6,000 20% $6,000 $30 $100 $20 $20 $35 $50 $75 $750 20%* $200* $5,000 30% $6,000 30%* 30%* 30%* 30%* 30%* 30%* 30%* 30%* 30%* 30%* $250(t2-4) Rx CYD $20/$40/$70/$250 $250(t2-4) Rx CYD $20/$40/$70/$250 $250(t2-4) Rx CYD $20/$40/$70/$250 $250(t2-4) Rx CYD $20/$40/$70/$250 $250(t2-4) Rx CYD $20/$40/$70/$250 $250(t2-4) Rx CYD $20/$40/$70/$250 $5000(t2-4) Medical CYD $25/$50/$75/$250 $6000(t2-4) Medical CYD $25/$50/$75/$250 $5000(t2-4) Medical CYD $25/$50/$75/$250 *After CYD ** No Rx CYD applies Member cost share including Copays, CYDs, Coinsurance and Rx out of pocket amounts accumulate to the applicable Medical Plan OOPM Family CYD and OOPMs are Embedded and are 2X the corresponding Individual CYD and OOPM amounts Bronze level plans have a combined Medical and Rx CYD Silver level plans have a separate and lower Rx CYD from the applicable Medical CYD All MyHPN Solutions Individual HMO plans have Embedded Pediatric Dental and Vision Coverage. All Covered Preventive Services have a $0 Copay. Benefit Schedules Ind_HMO_B2(2015), Ind_HMO_B1(2015), Ind_HMO_B3(2015), Ind_HMO_S3(2015), Ind_HMO_S2(2015), Ind_HMO_ S1(2015), Ind_HMO_S4(2015), Ind_HMO_G3(2015), Ind_HMO_G2(2015), Ind_HMO_G1(2015), Ind_HMO_G4(2015), Ind_HMO_Pltn1(2015), Ind_HMO_G5(2015), Ind_HMO_S5(2015), Ind_HMO_S6(2015). This is a summary of Covered Services. Please refer to the HPN Agreement of Coverage, Form No. HPN-Ind_AOC (2015), Attachment A Benefit Schedules (see below for benefit schedule form numbers) and Outpatient Prescription Drug Riders (see below for drug rider form numbers). For additional information, limitations and exclusions of coverage, copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments. Rx Riders Ind 4TierRx Gold(2015), Ind 4TierRx Silver(2015), Ind 4TierRx Platinum(2015), Ind 4TierRxComb Bronze(2015). [2] Individual MyHPN Solutions HMO Platinum 1 MyHPN Solutions HMO Gold 1 MyHPN Solutions HMO Gold 2 MyHPN Solutions HMO Gold 3 MyHPN Solutions HMO Gold 4 MyHPN Solutions HMO Gold 5 MyHPN Solutions HMO Silver 1 MyHPN Solutions HMO Silver 2 MyHPN Solutions HMO Silver 3 MyHPN Solutions HMO Silver 4 MyHPN Solutions HMO Silver 5 MyHPN Solutions HMO Silver 6 MyHPN Solutions HMO Bronze 1 MyHPN Solutions HMO Bronze 2 MyHPN Solutions HMO Bronze 3 Deductible Coinsurance (CYD) Per Member
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