Health Plan of Nevada, Inc. (HPN) Distinct Advantage POS Option 3 Attachment A Benefit Schedule This Plan includes a 12-month waiting period for maternity coverage. Lifetime Maximum Benefit: The combined lifetime maximum benefit for the Tier II Expanded Plan Provider and Tier III Non-Plan Provider plan services is $1,000,000 of EME. Tier I HMO Benefits apply when you obtain coverage or arrange for Covered Services through an HPN contracted Primary Care Physician. No claim forms are required, no deductible applies, and the Tier I HMO benefits provide a higher level of coverage with less out-of-pocket expenses than the Tier II Expanded Plan Provider or Tier III Non-Plan Provider benefits. Tier II Expanded Plan Provider Benefits apply when a Member obtains Covered Services from a Provider who is independently contracted by HPN, to provide services to Members enrolled in Distinct Advantage Option 3. The Member s out-of-pocket expenses will be higher than Tier I HMO benefits because the Member will be responsible for a Calendar Year deductible, coinsurance percentages and, in some instances, higher Copayments. Claim forms are not required when using contracted Tier II Expanded Plan Providers. Tier III Non-Plan Provider Benefits apply when a Member obtains Covered Services from a Tier III Non-Plan Provider. All benefits are subject to a Calendar Year deductible and coinsurance percentage, up to a Member s Calendar Year coinsurance maximum. Claim forms must be submitted for services received from Tier III Non-Plan Providers. Emergency Services: The Tier I HMO level of benefits will apply to Emergency Services provided at any duly licensed facility. Upon admission to a Tier III Non-Plan Hospital and stabilization of the emergency condition and safe for transfer as determined by the attending Physician, the Plan may require transfer to a Tier I HMO contracted facility in order to pay benefits at the Tier I HMO benefit level. Benefits for post-stabilization and follow-up care received at a Tier II Expanded Plan or Tier III Non-Plan Provider Hospital facility are subject to the applicable benefit tier. Calendar Year Deductible (CYD): Your CYD is $500 per Member and $1,500 per family. The CYD is a combined total of Eligible Medical Expenses (EME) for Tier II Expanded Plan Provider and Tier III Non-Plan Provider Covered Services. Coinsurance: After meeting your CYD, your coinsurance for most Tier II Expanded Plan Provider Covered Services is 20% of EME. Your coinsurance for most Tier III Non-Plan Provider Covered Services is 40% of EME. Coinsurance Maximum: After satisfying your CYD, your coinsurance is limited to a maximum of $2,000 of EME per Member per Calendar Year ($6,000 per family) if you use Tier II Expanded Plan Providers, and $4,000 of EME per Member per Calendar Year ($12,000 per family) if you use Tier III Non-Plan Providers. In no event will the total coinsurance you pay exceed $4,000 of EME per Member or $12,000 per family in any Calendar Year. Refer to the Distinct Advantage Point-of-Service Rider for amounts that do not accumulate to the Calendar Year coinsurance maximum. Note: You are responsible for all amounts exceeding the applicable benefit maximums, EME payments to Tier III Non-Plan Providers, and penalties for not complying with the Managed Care Program. Further, such amounts do not accumulate to your Calendar Year coinsurance maximum. Please read your HPN Agreement of Coverage and all other applicable Endorsements, Riders and Attachments, if any, to determine the governing contractual provisions for this Plan and to understand how EME payments to Providers are determined. Legal Documents Page 1
Medical Physician Services and Physician Consultations Office Visit/Consultation Primary Care Physician No $15 per visit $30 per visit After CYD, Member pays 40% Specialist Yes $30 per visit $45 per visit of EME. Prior Authorization is not required for Tier II and Tier III benefits. Inpatient Visit/Consultation Primary Care Physician Yes No charge No charge After CYD, Member pays 40% Specialist Yes No charge No charge of EME. Preventive Healthcare No $15 per visit Member pays 20% Member pays 40% Services of EME. of EME. a combined Tier II Not subject to CYD. Not subject to CYD. and Tier III maximum benefit of $500 per Calendar Year. Refer to your Agreement of Coverage for applicable age and frequency limitations. Laboratory Services Yes $15 per visit $15 per visit After CYD, Member Copayment is in addition to the pays 40% of EME. office visit Copayment and applies to services rendered in a Physician s office or at an independent lab. Routine Radiological and Yes $15 per visit $15 per visit After CYD, Member Non-Radiological Diagnostic pays 30% of EME. Imaging Services Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician s office or at an independent radiological facility. Page 2
Emergency Services Within Emergency Emergency the Service Area Services are Services are covered under the covered under the Urgent Care Facility Tier I HMO Tier I HMO Southwest Medical No $45 per visit Associates (SMA) Plan Provider Other Plan Provider No $50 per visit Non-Plan Provider No $60 per visit Physician s Services in Emergency Room Plan Provider No $25 per visit Non-Plan Provider No $75 per visit Emergency Room Plan Provider No $75 per visit Non-Plan Provider No $150 per visit Hospital Admission Emergency Stabilization No $150 per day not to Applies until stabilization and exceed $400 per safe for transfer as determined admission by the attending Physician. Legal Documents Lab and X-rays Plan Provider No $15 per visit Non-Plan Provider No $30 per visit The maximum benefit for Medically Necessary but non- Emergency Services received in an emergency room is 50% of EME. You are responsible for all amounts exceeding the Plan s applicable maximum Benefit and amounts exceeding The Plan s EME payment to Tier III Non-Plan Providers. Page 3
Emergency Services Outside Emergency Emergency the Service Area Services are Services are covered under the covered under the Urgent Care Facility No $60 per visit Tier I HMO Tier I HMO Physician s Services in Emergency Room No $75 per visit Emergency Room Facility No $150 per visit Hospital Admission Emergency Stabilization No $150 per day not to Applies until stabilization and exceed $400 per safe for transfer as determined admission. by the attending Physician. Lab and X-rays No $30 per visit The maximum benefit for Medically Necessary but non- Emergency Services received in an emergency room is 50% of EME. You are responsible for all amounts exceeding the Plan s applicable maximum Benefit and amounts exceeding the Plan s EME payment to Tier III Non-Plan Providers. Ambulance Services Emergency Emergency Ambulance Ambulance Emergency Ground Transport No $150 per trip Services are Services are covered under the covered under the Emergency Air Transport No 50% of EME per trip Tier I HMO Tier I HMO HPN Arranged Transfers Yes No charge Inpatient Hospital Facility Yes $150 per day not to After CYD, Member After CYD, Member Services exceed $400 per pays 20% of EME. pays 40% of EME. admission. Page 4
Outpatient Hospital Facility Yes $75 per admission After CYD, Member After CYD, Member and Ambulatory Surgical pays 20% of EME. pays 40% of EME. Facility Services, includes Sterilizations are Sterilizations are Sterilization covered under the covered under the Tier I HMO Tier I HMO Inpatient and Outpatient After CYD, Member After CYD, Member Physician Surgical Services pays 20% of EME. pays 40% of EME. Inpatient Hospital Facility Yes $100 per operative session Outpatient Hospital Facility Yes $75 per operative session Physician s Office Primary Care Physician Yes $15 per visit (inadditiontoofficevisit Copayment) Specialist (in addition to Yes $30 per visit office visit Copayment) Legal Documents Sterilizations in Physician s Yes $15 per surgery Sterilizations are Sterilizations are Office covered under the covered under the Tier I HMO Tier I HMO Assistant Surgical Services Yes $50 per operative After CYD, Member After CYD, Member session pays 20% of EME. pays 40% of EME. Anesthesia Services Yes $100 per operative After CYD, Member After CYD, Member session pays 20% of EME. pays 40% of EME. Gastric Restrictive Surgical Gastric Restrictive Gastric Restrictive Services Surgical Services Surgical Services are covered under are covered under Physician Surgical Services Yes 50% of EME. the Tier I HMO the Tier I HMO The maximum lifetime benefit for all Gastric Restrictive Surgical Services is $5,000 per Member. Page 5
Gastric Restrictive Surgical Gastric Restrictive Gastric Restrictive Services (continued) Surgical Services Surgical Services are covered under are covered under Complications Yes 50% of EME. the Tier I HMO the Tier I HMO The maximum lifetime benefit for all complications in connection with Gastric Restrictive Surgical Services is $5,000 per Member. Mastectomy Reconstructive Mastectomy Mastectomy Surgery Reconstructive Reconstructive Surgery is covered Surgery is covered Physician Surgical Services Yes $100 per operative under the Tier I under the Tier I session HMO HMO Prosthetic Device for Yes $750 per device Prosthetic Device Prosthetic Device Mastectomy Reconstruction for Mastectomy for Mastectomy Unlimited Reconstructive Reconstructive Surgery is covered Surgery is covered under the Tier I under the Tier I HMO HMO Oral Surgical Services After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Office Visit Yes $30 per visit Physician Surgical Services Inpatient Hospital Facility Yes $100 per operative session Outpatient Hospital Facility Yes $75 per operative session Organ and Tissue Transplant Organ Transplants/ Organ Transplants/ Surgical Services Retransplantations Retransplantations are covered under are covered under Inpatient Hospital Facility Yes $150 per day not to the Tier I HMO the Tier I HMO Services exceed $400 per admission. Subject to maximum Page 6
Organ and Tissue Transplant Organ Transplants/ Organ Transplants/ Surgical Services (continued) Retransplantations Retransplantations are covered under are covered under Physician Surgical Services Yes $100 per operative the Tier I HMO the Tier I HMO session. Transportation, Lodging and Yes No charge. Subject Meals to maximum The maximum benefit per Member per Transplant Benefit Period for transportation, lodging and meals is $10,000. The maximum daily limit for lodging and meals is $200. Procurement Yes No charge. Subject The maximum benefit per to maximum Member per Transplant Benefit Period for Procurement of the organ/tissue is $15,000 of EME. Retransplantation Services Yes 50% of EME. The 50% of EME for Retransplantation Services does not apply towards the Copayment maximum. Legal Documents The maximum benefit that will be paid for a Member for all Covered Transplant Procedures combined is $100,000. Home Healthcare Services After CYD, Member After CYD, Member Refer to your outpatient pays 20% of EME. pays 40% of EME. Prescription Drug Benefit Rider, if applicable, for your outpatient self-injectable covered drug Physician House Calls Yes $30 per visit Home Care Services Yes $30 per visit Page 7
Home Healthcare Services After CYD, Member After CYD, Member (continued) pays 20% of EME. pays 40% of EME. Private Duty Nursing Yes $15 per visit a combined Tier II and Tier III maximum benefit of thirty (30) visits per Calendar Year or $5,000, whichever is less. Hospice Care Services Hospice Care Hospice Care Services are Services are Inpatient Hospice Services Yes $150 per day not to covered under the covered under the exceed $400 per Tier I HMO Tier I HMO admission. Outpatient Hospice Services Yes No charge Inpatient Respite Services Yes $150 per day not to Limited to $1,500 per Member exceed $400 per per Calendar Year. admission. Subject to maximum Outpatient Respite Services Yes $15 per visit. Limited to $1,000 per Member per Calendar Year. Bereavement Services Yes $15 per visit. Limited to five (5) group therapy sessions or a maximum of $500, whichever is less. Treatment must be completed within six (6) months. Skilled Nursing Facility Yes $150 per day not to After CYD, Member After CYD, Member Services exceed $400 per pays 20% of EME. pays 40% of EME. a combined Tier I, II admission. Subject and III maximum benefit of 100 to maximum days per Member per Calendar Year. Page 8
Manual Manipulation (except Yes $15 per visit $30 per visit. After CYD, Member for reduction of fractures Pays 40% of EME. or dislocation) a combined Tier II and Tier III maximum benefit of $1,000 per Member per Calendar Year and $5,000 maximum lifetime Short-Term Rehabilitation After CYD, Member After CYD, Member Services pays 20% of EME. pays 40% of EME. Inpatient Hospital Facility Yes $150 per day not to exceed $400 per admission. Subject to Outpatient Hospital Facility Yes $15 per visit. All Inpatient and outpatient Short-Term Rehabilitation Services are subject to a combined Tier I, II, and III lifetime maximum benefit of sixty (60) calendar days. Legal Documents Durable Medical Equipment Yes No charge. Subject After CYD, Member After CYD, Member For rental or purchase at HPN s to maximum pays 50% of EME. pays 50% of EME. option. Limited to a combined Tier I, II, and III lifetime maximum benefit of $4,000. Genetic Disease Testing Yes 50% of EME per Genetic Disease Genetic Disease Services test. Testing Services Testing Services Includes Inpatient, outpatient, are Covered under are Covered under and independent laboratory the Tier I HMO the Tier I HMO services. Page 9
Infertility Office Visit Yes $30 per visit After CYD, Member After CYD, Member Evaluation pays 20% of EME. pays 40% of EME. Please refer to Covered Services Copayments for any Infertility procedures performed. Medical Supplies Yes No charge After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Other Diagnostic and After CYD, Member After CYD, Member Therapeutic Services pays 20% of EME. pays 40% of EME. Copayment is in addition to the office visit Copayment and applies to services rendered in a Physician s office or at an independent facility. Allergy Testing and Serum Yes $30 per visit Amniocentesis Yes $30 per visit Anti-Cancer Drug Therapy, non- Yes $30 per visit cancer related intravenous injection therapy or other Medically Necessary intravenous therapeutic services. Dialysis Yes $30 per visit Other services such as: Yes $30 per test or complex diagnostic imaging procedure (i.e., CAT scan, MRI); complex neurological or psychiatric testing or therapeutic services; pulmonary diagnostic services; vascular diagnostic and therapeutic services. Page 10
Other Diagnostic and After CYD, Member After CYD, Member Therapeutic Services pays 20% of EME. pays 40% of EME. (continued) Otologic Evaluations Yes $30 per visit Positron Emission Tomography Yes $750 per procedure (PET Scan) Therapeutic Radiology Yes $30 per visit Prosthetic and Orthotic Yes $750 per device. After CYD, Member After CYD, Member Devices maximum pays 20% of EME. pays 40% of EME. Limited to a combined Tier I, II, and III lifetime maximum maximum Benefit. maximum Benefit. benefit,including repairs, of $10,000. Self-Management and Treatment of Diabetes After CYD, Member pays 40% of EME. Legal Documents Education and Training No $15 per visit $30 per visit Supplies (except for Insulin No $5 per therapeutic $5 per therapeutic Pump Supplies) supply supply Insulin Pump Supplies Yes $15 per therapeutic $15 per therapeutic supply supply Equipment (except for Insulin Yes $20 per device $20 per device Pumps) Insulin Pumps Yes $100 per device $100 per device Special Food Products and Yes No charge. See After CYD, Member After CYD, Member Enteral Formulas pays 20% of EME. pays 40% of EME. Special Food Products are See maximum See maximum Limited to a combined Tier I, II, Page 11
Special Food Products and Enteral Formulas (continued) and III maximum benefit of $2,500 per Member per Calendar Year. Temporomandibular Yes 50% of EME. TMJ Treatment is TMJ Treatment is Joint Treatment (TMJ) covered under the covered under the Dental-related treatment is Tier I HMO Tier I HMO limited to $2,500 per Member per Calendar Year and $4,000 maximum lifetime benefit per Member. Mental Health Services Inpatient Hospital Facility Yes $150 per day not to After CYD, Member After CYD, Member Limited to a combined Tier I, II, exceed $400 per pays 20% of EME. pays 40% of EME. and III maximum benefit of thirty admission. Subject (30) days per Member per to maximum Calendar Year. Outpatient Treatment Group Therapy Yes $15 per visit After CYD, Member After CYD, Member Unlimited visits. pays 20% of EME. pays 40% of EME. Individual, Family and Partial Yes $20 per visit. After CYD, Member After CYD, Member Care Therapy** pays 20% of EME. pays 40% of EME. LimitedtoacombinedTier I, II, and III maximum benefit of twenty (20) visits per Member per Calendar Year. Benefit maximum does not apply to visits for medication management. Page 12
Mental Health Services (continued) **Partial care refers to a Coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Severe Mental Illness After CYD, Member After CYD, Member Services pays 20% of EME. pays 40% of EME. maximum Benefit. maximum Benefit. Inpatient Hospital Facility Yes $150 per day not to Limited to a combined Tier I, II, exceed $400 per and III maximum benefit of forty admission. Subject (40) days per Member per to maximum Calendar Year. Legal Documents Outpatient Treatment Yes $15 per visit. Limited to a combined Tier I, II, and III maximum benefit of forty (40) visits per Member per Calendar Year. Two (2) visits for partial or respite care, or a combination thereof, may be substituted for each day of Inpatient hospitalization not used by the Member. Benefit maximum does not apply to visits for medication management. Page 13
Substance Abuse Services After CYD, Member After CYD, Member pays 20% of EME. pays 40% of EME. Inpatient Rehabilitation Yes $150 per day not to Limited to a combined Tier I, II, exceed $400 per and III maximum benefit of admission. Subject $9,000 per Member per to maximum Calendar Year. Outpatient Rehabilition Group Therapy Yes $15 per visit. Individual, Family and Partial Yes $20 per visit. Care Therapy** Rehabilitation counseling services for all group, individual, family and partial care therapy is limited to a combined Tier I, II, and III maximum benefit of $2,500 per Member per Calendar Year. Inpatient Detoxification Yes $150 per day not to (treatment for withdrawal) exceed $400 per admission. Outpatient Detoxification Yes $15 per visit. Unlimited visits **Partial care refers to a Coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Page 14
Please note in addition to specified surgical Copayments and/or Coinsurance amounts, Member is also responsible for all other applicable facility and professional Copayments and/or Coinsurance as outlined in the Attachement A Benefit Schedule. Any and all amounts exceeding any stated maximum benefit amounts under the Plan do not accumulate to the calculation of the Calendar Year Copayment Maximum under Tier I. The Calendar Year Copayment Maximum for Tier I HMO basic health services is 200% of the total premium rate the Member would pay if he were enrolled under a Health Plan without Copayments. Contact HPN s Member Services Department at (702) 242-7300 or 1-800 777-1840 for the appropriate Calendar Year out-of-pocket maximum applicable to the Plan. *PAR (Prior Authorization Required) Except as otherwise noted, all Covered Services not provided by the Member s Primary Care Physician require Prior Authorization in the form of a written referral authorization from HPN. Please refer to your HPN Agreement of Coverage for additional information. (1) Tier I HMO benefits are provided by Health Plan of Nevada, Inc. (HPN), a Health Maintenance Organization (HMO). If Medically Necessary Covered Services are provided without Prior Authorization, for those services covered which require Prior Authorization and are available only under the Tier I HMO benefit, no benefits will be paid. (2) Tier II Expanded Plan Provider and Tier III Non-Plan Provider benefits are underwritten by HPN. If Medically Necessary Covered Services are provided without the required Prior Authorization, benefits are reduced to 50% of what the Member would have received with Prior Authorization. Legal Documents Page 15
$1 0/$35/$60 Individual Prescription Drug Benefit Summary Health Plan of Nevada, Inc. This is a summary of your prescription drug benefits and copayments under the Health Plan of Nevada (HPN) Prescription Drug Benefit Rider. A complete list of Preferred Covered Drugs can be obtained by calling HPN's Member Services Department at (702) 242-7300 or 1-800-777-1840. For more information, visit our web site at www.healthplanofnevada.com. Members will pay the lowest copayment when their Providers prescribe Preferred Generic Covered Drugs. Commonly Used Plan Terms Covered Drugs All prescriptions must be written for Covered Drugs in order to be eligible for payment under the Plan. Covered Drugs are those which are obtained with a prescription, approved by the FDA, dispensed by a licensed pharmacist, prescribed by a Plan Provider and not excluded by the Plan. Benefits for certain medically necessary Covered Drugs may require prior authorization from HPN. If such Covered Drugs are provided without prior authorization, there is no benefit coverage. Plan Pharmacies Members have access to local outlets of nationally recognized pharmacy chains. Plan Pharmacies are listed in the HPN Provider Directory. Prescriptions must be filled at Plan Pharmacies in order for benefits to be payable, unless dispensed in connection with an emergency or urgent condition. Maintenance Drugs Certain Preferred Maintenance Drugs may be available for up to a 90-day Maintenance Supply. This benefit allows members to take advantage of our money-saving Mail Order prescription program. Examples of Preferred Maintenance Drugs include medications that are used to treat certain chronic, life-threatening or long-term conditions such as diabetes, heart disease, high blood pressure and arthritis. Retail Plan Pharmacy Tier I: Preferred Generic Covered Drug $10 Copayment - up to a 30-day Therapeutic Supply Tier II: Preferred Brand Name Covered Drug* $35 Copayment - up to a 30-day Therapeutic Supply Tier III: Non-Preferred Generic or Brand Name Covered Drug* $60 Copayment - up to a 30-day Therapeutic Supply *If a Generic Covered Drug equivalent is available, Member pays the Tier I Covered Drug copayment plus the difference between the EME** of the Generic Covered Drug and the EME of the Brand Name Covered Drug to the Plan Pharmacy for each Therapeutic supply. Mail Order Plan Pharmacy Preferred Maintenance Covered Drugs The Member pays two (2) of the applicable copayments as outlined above for up to a 90-day Maintenance Supply for Preferred Maintenance Covered Drugs. Benefits for Mail Order prescriptions are available through the contracted HPN Mail Order Plan Pharmacy. **EME (Eligible Medical Expenses) means the network pharmacy contracted cost of the Covered Drug to the Plan. Prescription drug benefits are subject to Exclusions and Limitations which are shown in the Prescription Drug Benefit Rider, Form No. HPN-NV-Ind-3TierSIO-2006, HPN Evidence of Coverage, Attachment A Benefit Schedule, and any other applicable Riders. Copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments. This is a summary of covered prescription drugs. (02/07-5,000) 21NVHPN0797 PD-4428