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.
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.
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.
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.
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
Form No. HPN-IndDAP3-BS-2005
Page 1
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.
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Legal Documents
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.
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.
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Medical – Physician Services
and Physician Consultations
Office Visit/Consultation
• Primary Care Physician
No
$15 per visit
$30 per visit
Yes
$30 per visit
$45 per visit
Inpatient Visit/Consultation
• Primary Care Physician
Yes
No charge
No charge
•
Yes
No charge
No charge
After CYD,
Member pays 40%
of EME.
Preventive Healthcare
Services
Subject to a combined Tier II
and Tier III maximum benefit of
$500 per Calendar Year. Refer
to your Agreement of Coverage
for applicable age and
frequency limitations.
No
$15 per visit
Member pays 20%
of EME.
Not subject to CYD.
Subject to
maximum benefit.
Member pays 40%
of EME.
Not subject to CYD.
Subject to
maximum benefit.
Laboratory Services
Copayment is in addition to the
office visit Copayment and
applies to services rendered in
a Physician’s office or at an
independent lab.
Yes
$15 per visit
$15 per visit
After CYD, Member
pays 40% of EME.
Routine Radiological and
Non-Radiological Diagnostic
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.
Yes
$15 per visit
$15 per visit
After CYD, Member
pays 30% of EME.
• Specialist
Prior Authorization is not
required for Tier II and Tier III
benefits.
Specialist
Form No. HPN-IndDAP3-BS-2005
Page 2
After CYD,
Member pays 40%
of EME.
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Emergency Services Within
the Service Area
Urgent Care Facility
• Southwest Medical
Associates (SMA) Plan
Provider
Emergency
Services are
covered under the
Tier I HMO benefit.
No
$45 per visit
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
•
No
$75 per visit
Emergency Room
• Plan Provider
No
$75 per visit
•
No
$150 per visit
No
$150 per day not to
exceed $400 per
admission
Lab and X-rays
• Plan Provider
No
$15 per visit
•
No
$30 per visit
Non-Plan Provider
Non-Plan Provider
Hospital Admission –
Emergency Stabilization
Applies until stabilization and
safe for transfer as determined
by the attending Physician.
Non-Plan Provider
Legal Documents
•
Emergency
Services are
covered under the
Tier I HMO benefit.
The maximum benefit for
Medically Necessary but nonEmergency 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.
Form No. HPN-IndDAP3-BS-2005
Page 3
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Emergency Services Outside
the Service Area
Urgent Care Facility
No
$60 per visit
Physician’s Services in
Emergency Room
No
$75 per visit
Emergency Room Facility
No
$150 per visit
No
$150 per day not to
exceed $400 per
admission.
No
$30 per visit
Hospital Admission –
Emergency Stabilization
Applies until stabilization and
safe for transfer as determined
by the attending Physician.
Lab and X-rays
Emergency
Services are
covered under the
Tier I HMO benefit.
Emergency
Services are
covered under the
Tier I HMO benefit.
Emergency
Ambulance
Services are
covered under the
Tier I HMO benefit.
Emergency
Ambulance
Services are
covered under the
Tier I HMO benefit.
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
The maximum benefit for
Medically Necessary but nonEmergency 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 – Ground Transport
No
$150 per trip
Emergency – Air Transport
No
50% of EME per trip
HPN Arranged Transfers
Yes
No charge
Inpatient Hospital Facility
Services
Yes
$150 per day not to
exceed $400 per
admission.
Form No. HPN-IndDAP3-BS-2005
Page 4
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Outpatient Hospital Facility
and Ambulatory Surgical
Facility Services, includes
Sterilization
Yes
$75 per admission
Inpatient and Outpatient
Physician Surgical Services
Yes
$100 per operative
session
Outpatient Hospital Facility
Yes
$75 per operative
session
Yes
$15 per visit
Physician’s Office
• Primary Care Physician
(in addition to office visit
Copayment)
After CYD, Member
pays 40% of EME.
Sterilizations are
covered under the
Tier I HMO benefit.
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Legal Documents
Inpatient Hospital Facility
After CYD, Member
pays 20% of EME.
Sterilizations are
covered under the
Tier I HMO benefit.
•
Specialist (in addition to
office visit Copayment)
Yes
$30 per visit
•
Sterilizations in Physician’s
Office
Yes
$15 per surgery
Sterilizations are
covered under the
Tier I HMO benefit.
Sterilizations are
covered under the
Tier I HMO benefit.
Assistant Surgical Services
Yes
$50 per operative
session
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Anesthesia Services
Yes
$100 per operative
session
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Gastric Restrictive
Surgical Services
are covered under
the Tier I HMO
benefit.
Gastric Restrictive
Surgical Services
are covered under
the Tier I HMO
benefit.
Gastric Restrictive Surgical
Services
Physician Surgical Services
The maximum lifetime benefit
for all Gastric Restrictive
Surgical Services is $5,000
per Member.
Form No. HPN-IndDAP3-BS-2005
Yes
50% of EME.
Subject to
maximum benefit.
Page 5
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Gastric Restrictive Surgical
Services (continued)
Complications
The maximum lifetime benefit
for all complications in
connection with Gastric
Restrictive Surgical Services is
$5,000 per Member.
Yes
50% of EME.
Subject to
maximum benefit.
Mastectomy Reconstructive
Surgery
Physician Surgical Services
Yes
$100 per operative
session
Prosthetic Device for
Mastectomy Reconstruction
Unlimited
Yes
$750 per device
Oral Surgical Services
Office Visit
Yes
$30 per visit
Physician Surgical Services
• Inpatient Hospital Facility
Yes
$100 per operative
session
•
Yes
$75 per operative
session
Outpatient Hospital Facility
Organ and Tissue Transplant
Surgical Services
Inpatient Hospital Facility
Services
Form No. HPN-IndDAP3-BS-2005
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
Page 6
Gastric Restrictive
Surgical Services
are covered under
the Tier I HMO
benefit.
Gastric Restrictive
Surgical Services
are covered under
the Tier I HMO
benefit.
Mastectomy
Reconstructive
Surgery is covered
under the Tier I
HMO benefit.
Mastectomy
Reconstructive
Surgery is covered
under the Tier I
HMO benefit.
Prosthetic Device
for Mastectomy
Reconstructive
Surgery is covered
under the Tier I
HMO benefit.
Prosthetic Device
for Mastectomy
Reconstructive
Surgery is covered
under the Tier I
HMO benefit.
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Organ Transplants/
Retransplantations
are covered under
the Tier I HMO
benefit.
Organ Transplants/
Retransplantations
are covered under
the Tier I HMO
benefit.
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Organ and Tissue Transplant
Surgical Services (continued)
Yes
$100 per operative
session. Subject to
maximum benefit.
Transportation, Lodging and
Meals
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.
Yes
No charge. Subject
to maximum
benefit.
Procurement
The maximum benefit per
Member per Transplant Benefit
Period for Procurement of the
organ/tissue is $15,000 of EME.
Yes
No charge. Subject
to maximum
benefit.
Retransplantation Services
The 50% of EME for
Retransplantation Services
does not apply towards the
Copayment maximum.
Yes
50% of EME.
Subject to
maximum benefit.
Organ Transplants/
Retransplantations
are covered under
the Tier I HMO
benefit.
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Legal Documents
Physician Surgical Services
Organ Transplants/
Retransplantations
are covered under
the Tier I HMO
benefit.
The maximum benefit that will
be paid for a Member for all
Covered Transplant Procedures
combined is $100,000.
Home Healthcare Services
Refer to your outpatient
Prescription Drug Benefit Rider,
if applicable, for your outpatient
self-injectable covered drug
benefit.
Physician House Calls
Yes
$30 per visit
Home Care Services
Yes
$30 per visit
Form No. HPN-IndDAP3-BS-2005
Page 7
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Home Healthcare Services
(continued)
Private Duty Nursing
Yes
$15 per visit
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Hospice Care
Services are
covered under the
Tier I HMO benefit.
Hospice Care
Services are
covered under the
Tier I HMO benefit.
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Subject to 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
Inpatient Hospice Services
Yes
$150 per day not to
exceed $400 per
admission.
Outpatient Hospice Services
Yes
No charge
Inpatient Respite Services
Limited to $1,500 per Member
per Calendar Year.
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
Outpatient Respite Services
Limited to $1,000 per Member
per Calendar Year.
Yes
$15 per visit.
Subject to
maximum benefit.
Bereavement Services
Limited to five (5) group therapy
sessions or a maximum of
$500, whichever is less.
Treatment must be completed
within six (6) months.
Yes
$15 per visit.
Subject to
maximum benefit.
Skilled Nursing Facility
Services
Subject to a combined Tier I, II
and III maximum benefit of 100
days per Member per Calendar
Year.
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
Form No. HPN-IndDAP3-BS-2005
Page 8
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Manual Manipulation (except
for reduction of fractures
or dislocation)
Yes
$15 per visit
$30 per visit.
Subject to
maximum benefit.
After CYD, Member
Pays 40% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Subject to a combined Tier II
and Tier III maximum benefit
of $1,000 per Member per
Calendar Year and $5,000
maximum lifetime benefit.
Short-Term Rehabilitation
Services
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum benefit.
Outpatient Hospital Facility
Yes
$15 per visit.
Subject to
maximum benefit.
Durable Medical Equipment
For rental or purchase at HPN’s
option. Limited to a combined
Tier I, II, and III lifetime
maximum benefit of $4,000.
Yes
No charge. Subject
to maximum
benefit.
After CYD, Member
pays 50% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 50% of EME.
Subject to
maximum benefit.
Genetic Disease Testing
Services
Includes Inpatient, outpatient,
and independent laboratory
services.
Yes
50% of EME per
test.
Genetic Disease
Testing Services
are Covered under
the Tier I HMO
benefit.
Genetic Disease
Testing Services
are Covered under
the Tier I HMO
benefit.
Legal Documents
Inpatient Hospital Facility
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.
Form No. HPN-IndDAP3-BS-2005
Page 9
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Infertility Office Visit
Evaluation
Please refer to Covered
Services Copayments for any
Infertility procedures performed.
Yes
$30 per visit
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Medical Supplies
Yes
No charge
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
Other Diagnostic and
Therapeutic Services
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, noncancer related intravenous
injection therapy or other
Medically Necessary
intravenous therapeutic
services.
Yes
$30 per visit
Dialysis
Yes
$30 per visit
Other services such as:
• complex diagnostic imaging
(i.e., CAT scan, MRI);
• complex neurological or
psychiatric testing or
therapeutic services;
• pulmonary diagnostic
services;
• vascular diagnostic and
therapeutic services.
Yes
$30 per test or
procedure
Form No. HPN-IndDAP3-BS-2005
Page 10
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Other Diagnostic and
Therapeutic Services
(continued)
Yes
$30 per visit
Positron Emission Tomography
(PET Scan)
Yes
$750 per procedure
Therapeutic Radiology
Yes
$30 per visit
Prosthetic and Orthotic
Devices
Limited to a combined Tier I, II,
and III lifetime maximum
benefit,including repairs, of
$10,000.
Yes
$750 per device.
Subject to maximum
benefit.
After CYD, Member
pays 40% of EME.
After CYD, Member
pays 20% of EME.
Subject to
maximum Benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum Benefit.
After CYD, Member
pays 40% of EME.
Self-Management and
Treatment of Diabetes
Education and Training
No
$15 per visit
$30 per visit
Supplies (except for Insulin
Pump Supplies)
No
$5 per therapeutic
supply
$5 per therapeutic
supply
•
Insulin Pump Supplies
Yes
$15 per therapeutic
supply
$15 per therapeutic
supply
Equipment (except for Insulin
Pumps)
Yes
$20 per device
$20 per device
•
Yes
$100 per device
$100 per device
Yes
No charge. See
maximum benefit.
After CYD, Member
pays 20% of EME.
See maximum
benefit.
Insulin Pumps
Special Food Products and
Enteral Formulas
Special Food Products are
Limited to a combined Tier I, II,
Form No. HPN-IndDAP3-BS-2005
Page 11
After CYD, Member
pays 40% of EME.
See maximum
benefit.
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Legal Documents
Otologic Evaluations
After CYD, Member
pays 20% of EME.
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Special Food Products and
Enteral Formulas (continued)
and III maximum benefit of
$2,500 per Member per
Calendar Year.
Temporomandibular
Joint Treatment (TMJ)
Dental-related treatment is
limited to $2,500 per Member
per Calendar Year and $4,000
maximum lifetime benefit per
Member.
Yes
50% of EME.
Subject to
maximum benefit.
TMJ Treatment is
covered under the
Tier I HMO benefit.
TMJ Treatment is
covered under the
Tier I HMO benefit.
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Outpatient Treatment
• Group Therapy
Unlimited visits.
Yes
$15 per visit
After CYD, Member
pays 20% of EME.
After CYD, Member
pays 40% of EME.
•
Yes
$20 per visit.
Subject to
maximum benefit.
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
Mental Health Services
Inpatient Hospital Facility
Limited to a combined Tier I, II,
and III maximum benefit of thirty
(30) days per Member per
Calendar Year.
Individual, Family and Partial
Care Therapy**
Limited to a combined Tier
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.
Form No. HPN-IndDAP3-BS-2005
Page 12
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
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
Services
Inpatient Hospital Facility
Limited to a combined Tier I, II,
and III maximum benefit of forty
(40) days per Member per
Calendar Year.
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
Outpatient Treatment
Limited to a combined Tier I, II,
and III maximum benefit of forty
(40) visits per Member per
Calendar Year.
Yes
$15 per visit.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum Benefit.
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.
Form No. HPN-IndDAP3-BS-2005
Page 13
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Legal Documents
After CYD, Member
pays 20% of EME.
Subject to
maximum Benefit.
Benefit Schedule
Covered Services
and Limitations
*
P
A
R
Tier I HMO
Benefits(1)
(Copayments)
Tier II
Expanded
Plan Provider
Benefits(2)
Tier III
Non-Plan
Provider
Benefits(2)
(CYD, Coinsurance and/or
Copayments) HPN pays the remainder
of the EME balance up to the applicable
Calendar Year and/or Covered Service
maximum benefit.
Substance Abuse Services
Inpatient Rehabilitation
Limited to a combined Tier I, II,
and III maximum benefit of
$9,000 per Member per
Calendar Year.
Yes
$150 per day not to
exceed $400 per
admission. Subject
to maximum
benefit.
Outpatient Rehabilition
• Group Therapy
Yes
$15 per visit.
Subject to
maximum benefit.
•
Yes
$20 per visit.
Subject to
maximum benefit.
Inpatient Detoxification
(treatment for withdrawal)
Yes
$150 per day not to
exceed $400 per
admission.
Outpatient Detoxification
Unlimited visits
Yes
$15 per visit.
Individual, Family and Partial
Care Therapy**
After CYD, Member
pays 20% of EME.
Subject to
maximum benefit.
After CYD, Member
pays 40% of EME.
Subject to
maximum benefit.
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.
**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.
Form No. HPN-IndDAP3-BS-2005
Page 14
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
Benefit Schedule
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
Form No. HPN-IndDAP3-BS-2005
Page 15
(NV 2005\Individual\HMO\Form No.) 21NVHMOBE_DAP3
P.O. Box 15645, Las Vegas, Nevada 89114-5645
Disclosure Summary for the Individual
Distinct Advantage – POS Option 3
This Plan includes a consecutive 12-month Maternity Waiting Period that must be
satisfied before benefit coverage is provided for pregnancy.
This Disclosure Summary outlines certain
provisions of the Health Plan of Nevada, Inc.
(“HPN”) Distinct Advantage - POS Option 3
Agreement of Coverage (“AOC”). Please read
your AOC in its entirety for governing
contractual provisions and refer to your
Attachment A, Benefit Schedule for
additional information on benefits.
Carefully read the information contained in this
Disclosure Summary to understand:
1. How some expenses are considered;
2. The meaning of certain words; and
3. Some specific requirements which will
maximize your benefits.
To understand exactly what coverage you have
and what your responsibilities are, please read
your HPN AOC, applicable Riders and
Attachments.
Distinct Advantage - POS Option 3 is a "Point
of Service" plan that offers Members flexibility
and freedom of choice to use either Tier I Health
Maintenance Organization ("HMO") benefits,
Tier II Expanded Plan Provider benefits or Tier
III Non-Plan Provider benefits whenever
healthcare services are needed. Benefits for
certain Covered Services may only be payable
when provided by the Tier I HMO Plan Provider.
Certain Covered Services are subject to benefit
maximums specific to the benefit level accessed
which limit the amount of benefit payments you
may receive. Please refer to the Attachment A
Benefit Schedule for specific information on
these benefit maximums.
Tier II - Expanded Plan Provider Benefits
apply when a Member obtains Covered Services
from a Plan Provider from the HPN Expanded
Plan Provider network. Certain Covered
Services require Prior Authorization from HPN’s
Managed Care Program in order for the Member
to receive maximum benefits. The Member’s
out-of-pocket expenses will be higher than they
would under the Tier I HMO benefits because
the Member will be responsible for higher
Copayments or a Calendar Year Deductible
(“CYD”), and/or Coinsurance.
Tier III - Non-Plan Provider Benefits apply
when a Member obtains Covered Services from
a Non-Plan Provider. Certain Covered Services
require Prior Authorization from HPN’s Managed
Care Program in order for the Member to
receive maximum benefits. All benefits are
subject to a CYD and Coinsurance
percentageup to a Member’s Calendar Year
Coinsurance Maximum, as set forth in the
Attachment A Benefit Schedule. Emergency
Services: Benefits and Copayments for
Emergency Services received from Tier II and
Tier III Providers are subject to varying
Copayment amounts and limitations shown in
the Attachment A Benefit Schedule and as set
forth in the HPN AOC.
The Tier I HMO level of benefits will apply to
Emergency Services provided at any duly
licensed Plan facility. When a Member is
admitted to a Non-Plan Provider Hospital, upon
stabilization of the emergency condition and
establishment that Member is 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 poststabilization and follow-up care received at a
Tier II or Tier III Provider Hospital facility are
subject to the applicable benefit tier.
Tier I HMO Benefits apply when a Member
obtains Covered Services or has them arranged
by a Plan Provider from the Tier I HMO Plan
Provider network and when the care has been
Prior Authorized by HPN, if required. No claim
forms are required for Tier I HMO benefits when
Covered Services are received from Plan
Providers. Tier I HMO benefits provide a higher
level of coverage with less out-of-pocket
expenses to the Member.
Form No. HPN--DisSum- DAP3-2005
NOTE: In addition to any required Copayments
or CYD and Coinsurance, you are responsible
1
Leg102\NV 2005\Individual\Form #
services, if the charges exceed $200;
(c) All outpatient tests, including technical and
professional services, (except routine xrays) if the charges for such tests exceed
$200, including, for example, but not limited
to, the following: angiograms; echocardiograms; EEGs; EMGs; and nerve conduction
studies; Holter monitors (heart monitor-24
hours); myelograms; non-invasive vascular
studies; psychological testing; pulmonary
function tests; CAT scans, MRI scans,
nuclear scans; sleep apnea studies; and
treadmill stress tests (cardiac exercise
tests); (see paragraph (d) below); and
(d) All outpatient courses of treatment,
including, for example, but not limited to, the
following:
allergy testing/treatment (e.g.
skin, RAST); angioplasty; anti-cancer drug
therapy; dialysis; Home Health Care;
physiotherapy or manual manipulation;
radiation
therapy;
and
rehabilitation
(physical, speech, occupational, other).
for expenses which exceed the Eligible Medical
Expense (“EME”) payments to Tier III Non-Plan
Providers, amounts that exceed applicable
maximum benefit payments, and penalties for
not complying with HPN’s Managed Care
program. Claim forms must be submitted for
services received from Tier III Non-Plan
Providers.
Important Information
Benefits for all Tier I HMO Covered Services not
provided by the Member's Primary Care
Provider (“PCP”) require Prior Authorization from
the PCP and the Plan in the form of a written
referral
authorization.
Covered
Services
requiring Prior Authorization and review through
the Managed Care Program include, but are not
limited to all hospitalizations, Inpatient and
outpatient surgeries, diagnostic studies, Home
Health Care services, Mental Health and
Substance Abuse Services, prosthetics and all
services provided by Tier III Non-Plan Providers.
Failure to comply with the Prior Authorization
requirement will result in the Member being
responsible for the costs incurred for those
medical services which required Prior
Authorization but was not received.
Exclusions and Limitations
This section tells you what services or supplies
are excluded from coverage under this
Agreement.
•
Emergency Covered Services do not require
Prior Authorization. Please read your HPN AOC
and Attachment A, Benefit Schedule to
determine what Covered Services require Prior
Authorization.
•
Certain Tier II Expanded Plan Provider and Tier
III Non-Plan Provider non-Emergency Covered
Services require Prior Authorization from HPN’s
Managed Care Program in order for the Member
to receive maximum benefits. Failure to comply
with the Prior Authorization requirements will
result in a reduction of benefits.
•
Benefits for Tier II Expanded Plan Provider
benefits or Tier III Non-Plan Provider Covered
Services which are not Prior Authorized by the
Managed Care Program will be reduced to 50%
of what the Member would have received if the
services had been Prior Authorized. Benefits for
Tier II Expanded Plan Provider benefits or Tier
III Non-Plan Provider Covered Services which
require Prior Authorization and review through
HPN’s Managed Care Program include:
(a) All elective Inpatient admissions and
extensions of stay beyond the original
certified length of stay to a Hospital or
Skilled Nursing Facility;
(b) All outpatient surgery provided in any
setting, including technical and professional
Form No. HPN-DisSum-DAP3- 2005
•
•
•
2
Services or supplies for which coverage is
not specifically provided in this AOC,
complications resulting from non-Covered
Services, or services which are not
Medically Necessary, whether or not
recommended or provided by a Provider.
Services not provided, directed, and/or Prior
Authorized by a Member's PCP and the
Managed Care Program, except for; 1)
Emergency Services; or 2) Urgently Needed
Services received outside the Service Area.
Personal comfort, hygiene, or convenience
items such as a Hospital television,
telephone, or private room when not
Medically Necessary. Housekeeping or
meal services as part of Home Health
Care.
Modifications to a place of
residence,
including
equipment
to
accommodate physical handicaps or
disabilities.
Services for a private room in excess of the
average semi-private room and board rate.
Dental or orthodontic splints or dental
prostheses, or any treatment on or to teeth,
gums, or jaws and other services
customarily provided by a dentist. Charges
for dental services in connection with
temporomandibular joint dysfunction are
also not covered unless they are
determined to be Medically Necessary.
Such dental-related services are subject to
the limitations shown in the Benefit
Schedule.
Except for reconstructive surgery following
a mastectomy, cosmetic procedures to
Leg102\NV 2005\Individual\Form #
•
•
•
•
•
•
improve appearance without restoring a
physical bodily function.
Third-party
physical
exams
for
employment, licensing, insurance, school,
camp, sports, or adoption purposes.
Immunizations related to foreign travel.
Expenses for medical reports, including
presentation and preparation. Exams or
treatment ordered by a court, or in
connection with legal proceedings if not
Medically Necessary or a Covered Service.
The following infertility services and
supplies are excluded, in addition to any
other infertility services or supplies
determined by HPN not to be Medically
Necessary or not Prior Authorized by the
Managed Care Program;
1. Advanced reproductive techniques
such as embryo transplants, in vitro
fertilization,
GIFT
and
ZIFT
procedures,
assisted
hatching,
intracytoplasmic sperm injection, egg
retrieval via laparoscope or needle
aspiration,
sperm
preparation,
specialized sperm retrieval techniques,
sperm washing except prior to artificial
insemination if required;
2. Home pregnancy or ovulation tests;
3. Sonohysterography;
4. Monitoring of ovarian response to
stimulants;
5. CT or MRI of sella turcica unless
elevated prolactin level;
6. Evaluation for sterilization reversal;
7. Laparoscopy;
8. Ovarian wedge resection;
9. Removal of fibroids, uterine septae and
polyps;
10. Open or laparoscopic resection,
fulguration, or removal of endometrial
implants;
11. Surgical lysis of adhesions;
12. Surgical tube reconstruction.
Services for the treatment of sexual
dysfunction or inadequacies, including, but
not limited to, impotence and implantation
of a penile prosthesis.
Reversal of
surgically
performed
sterilization
or
subsequent resterilization.
Elective abortions.
Except as provided in the Covered
Services Gastric Restrictive Surgery
section, weight reduction procedures are
excluded. Also excluded are any weight
loss
programs,
whether
or
not
recommended, provided or prescribed by a
Physician or other medical Practitioner.
Treatment of marital or family problems;
occupational, religious, or other social
maladjustments;
chronic
behavior
disorders, codependency; impulse control
disorders; organic disorders, learning
Form No. HPN-DisSum- DAP3- 2005
•
•
•
•
•
•
•
•
•
•
•
•
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3
disabilities or mental retardation or any
Severe Mental Illness as defined in the
AOC and otherwise covered under the
Severe Mental Illness Covered Services
section. For purposes of this exclusion,
“chronic” means any condition existing for
more than six (6) months.
Institutional care which is determined to be
for the primary purpose of controlling
Member’s environmental and Custodial
Care, domiciliary care, convalescent care
(other than Skilled Nursing Care) or rest
cures.
Vision exams to determine refractive errors
of vision and eyeglasses or contacts.
Coverage is provided for vision exams only
when required to diagnose an Illness or
Injury.
Hearing exams to determine the need for
or the appropriate type of hearing aid or
similar. Coverage is provided for hearing
exams only when required to diagnose an
Illness or Injury.
Ecological or environmental medicine. Use
of chelation, orthomolecular substances;
use of substances of animal, vegetable,
chemical or mineral origin not specifically
approved by the FDA as effective for
treatment;
electrodiagnosis;
Hahnemannian dilution and succession;
magnetically energized geometric patterns;
replacement of metal dental fillings; laetrile,
gerovital.
Services for chronic, intractable pain by a
pain control center or under a pain control
program.
Acupuncture or hypnosis.
Treatment of an Illness or Injury caused by
or arising out of a riot, declared or
undeclared war or act of war, insurrection;
rebellion; or armed invasion or aggression.
Treatment of an occupational Injury or
Illness which is any injury or Illness arising
out of or in the course of employment for
pay or profit.
Travel and accommodations, whether or
not recommended by prescribed by a
Provider.
Vitamins, herbal medicines, appetite
suppressants, and other over-the-counter
drugs. Drugs and medicines approved by
the FDA for experimental or investigational
use.
Any services provided before the Effective
Date or after the termination of coverage.
Care for conditions that federal, state or
local law requires to be treated in a public
facility for which a charge is not normally
made.
Any equipment or supplies that condition
the air, arch supports, support stockings,
special shoe accessories or corrective
shoes unless they are an integral part of a
lower-body brace, heating pads, hot water
bottles, wigs and their care and other
primarily non-medical equipment.
Special formulas, food supplements other
Leg102\NV 2005\Individual\Form #
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
than as specifically covered or special diets
on an outpatient basis. (Except for the
treatment of inherited metabolic disease)
Services, supplies or accommodations
provided without cost to the Member or
which the Member is not legally required to
pay.
Milieu therapy, biofeedback, behavior
modification, sensitivity training, hypnosis,
hydrotherapy,
electrohypsnoisis,
electrosleep
therapy,
electronarcosis,
narcosynthesis,
rolffing,
residential
treatment, vocational rehabilitation and
wilderness programs.
Experimental or investigational treatment
or devices.
Sports medicine treatment plans intended
to primarily improve athletic ability.
Radial keratotomy or any surgical
procedure for the improvement of vision
when vision can be made adequate
through the use of glasses or contact
lenses.
Any services given by a Provider to himself
or to members of his family.
Ambulance services when a Member could
be safely transported by other means. Air
ambulance services when a Member could
be
safely
transported
by
ground
Ambulance or other means.
Late discharge billing and charges
resulting from a canceled appointment or
procedure.
If you are eligible for Medicare, any
services covered by Medicare under Parts
A and B are excluded to the extent actually
paid for by Medicare.
Autologous blood donations.
Any services or supplies provided in
connection with pregnancy or childbirth
except when provided in connection with
Complications of Pregnancy until the date
following the expiration date of the twelve
(12) consecutive month Maternity Waiting
Period.
Durable Medical Equipment including
administration, maintenance and operating
costs of such equipment, if the equipment
is not Medically Necessary or Prior
Authorized. Durable Medical Equipment
includes but is not limited to; outpatient
oxygen, wheelchairs, crutches, walkers,
hospital beds and traction equipment.
Any services or supplies rendered in
connection with Member acting as or
utilizing the services of a surrogate mother.
An attempt to commit or committing a
felony by the Member.
Covered Services received in connection
with a clinical trial or study which includes
the following:
1. Drugs and medicines approved by the
FDA for experimental or investigational
use except when prescribed for the
Form No. HPN-DisSum-DAP3- 2005
•
treatment of cancer or chronic fatigue
syndrome under a clinical trial or study
approved by the Plan.
2. Any portion of the clinical trial or study
that is customarily paid for by a
government
or
a
biotechnical,
pharmaceutical or medical industry;
3. Healthcare
services
that
are
specifically excluded from coverage
under this Plan regardless of whether
such services are provided under the
clinical trial or study;
4. Healthcare
services
that
are
customarily provided by the sponsors
of the clinical trial or study free of
charge to the Member in the clinical
trial or study;
5. Extraneous expenses related to
participation in the clinical trial or study
including, but not limited to, travel,
housing and other expenses that a
Member may incur;
6. Any expenses incurred by a person
who accompanies the Member during
the clinical trial or study;
7. Any item or service that is provided
solely to satisfy a need or desire for
data collection or analysis that is not
directly related to the clinical
management of the Member; and
8. Any cost for the management of
research relating to the clinical trial or
study.
HPN will not be liable for any delay or failure
to provide or arrange for Covered Services if
the delay or failure is caused by the
following:
• Natural disaster.
• War.
• Riot.
• Civil insurrection.
• Epidemic.
• Or any other emergency beyond HPN’s
control.
In the event of one of these types of
emergencies, HPN and its Plan Providers will
provide the Covered Services shown in the
AOC to the extent practical according to their
best judgment.
During the first twelve (12) consecutive months
of coverage under the Agreement, no benefits
will be payable for a Preexisting Condition or
any complications thereof, with exception to
Complications of Pregnancy.
4
Leg102\NV 2005\Individual\Form #
“Coinsurance” means the percentage of the
charges billed or the percentage of Eligible
Medical Expenses, whichever is less, that a
Member must pay a Provider for Covered
Services. Coinsurance amounts are to be paid
by the Member directly to the Provider who bills
for the Covered Services. (See Attachment A
Benefit Schedule.)
Maternity Waiting Period
No benefits will be paid for pregnancy or
obstetrical delivery under this Plan, except
when
provided
in
connection
with
Complications of Pregnancy, until the
expiration of the twelve (12) consecutive month
Maternity Waiting Period commencing on the
Effective Date of coverage.
“Coinsurance
Maximum”
means
the
maximum amount to be paid by a Subscriber
as Coinsurance for Covered Services per
Calendar Year. Please refer to Attachment A,
Benefit Schedule, for specific information on
how the Coinsurance Maximum for your Plan is
determined. The following are not included in
the Calendar Year Coinsurance Maximum:
Please read your HPN AOC and Attachment A,
Benefit Schedule for governing provisions,
limitations and exclusions.
Premiums
HPN reserves the right to establish a revised
schedule of premium payments provided it gives
the Subscriber sixty (60) days prior written
notice.
ƒ
ƒ
ƒ
The following factors may be considered in the
premium rate determination: the age and gender
of each individual, family composition, the
geographical area, occupation and health
status. The selection of variable Copayments
will also affect the respective rates. Upon
renewal, HPN will consider changes in case
characteristics, including each individual's
attained age, change in base premium rates and
an adjustment factor for claims experience and
health status.
ƒ
ƒ
ƒ
ƒ
ƒ
Renewability
Coverage under the Plan is guaranteed
renewable at the option of the Subscriber,
except for the following reasons for which
coverage may be terminated:
1) nonpayment of required premiums;
2) misrepresentation by the Subscriber of any
information regarding the Subscriber or
Dependent covered under the Plan or other
information regarding eligibility for coverage
under the Plan;
3) failure to comply with any applicable
underwriting requirements; or
4) if HPN discontinues transacting healthcare
coverage or insurance in the geographic
area of this state where the Subscriber is
located, provided HPN notifies the
commissioner and all affected Subscribers
at least one hundred eighty (180) days in
advance.
“Creditable Coverage” means certain types
of coverage which are credited against and
reduce the length of the Preexisting Condition
limitation period. Coverage prior to a lapse in
coverage of sixty-three (63) or more days is not
credited toward any Preexisting Condition
limitation period.
“Deductible” means the portion of the
covered expenses billed by Providers each
Calendar Year that a Member must pay, either
in the aggregate or for a particular service
before the Plan will make any benefit payments
for Covered Services under the Tier II
Expanded Plan Provider benefits and Tier III
Non-Plan Provider benefit levels.
“Eligible Medical Expenses” or “EME” means
charges up to the HPN Reimbursement
Schedule amount incurred by a Member while
he/she is covered under this Plan for Covered
Services. Plan Providers have agreed to accept
Glossary
Form No. HPN-DisSum- DAP3- 2005
Copayments;
Deductibles;
Any expenses for reductions in benefits
resulting from Subscriber’s failure to
comply with HPN’s Managed Care
Program, including the inappropriate use
of an emergency room facility for a
condition which does not require
Emergency Services;
Any expenses for Covered Services in
excess of the Eligible Medical Expenses;
Amounts paid in connection with selfinjectable medication;
Expenses for services not covered by the
Plan;
Expenses in excess of the Calendar Year,
lifetime, or per illness maximum benefits
shown in the Attachment A Benefit
Schedule; or
Mental Health and Substance Abuse
Services.
5
Leg102\NV 2005\Individual\Form #
HPN’s Reimbursement Schedule amount as
payment in full for Covered Services, plus the
Member’s
payment
of
any
applicable
Copayment, Deductible, or Coinsurance,
whereas Non-Plan Providers have not.
Members who use the services of Non-Plan
Providers will receive no benefit payments or
reimbursement for charges in excess of HPN’s
Reimbursement Schedule for any Covered
Services.
accommodations will not automatically be
considered Medically Necessary simply
because they were prescribed by a
Physician.
“Plan” means the HPN Agreement of
Coverage and any Attachments, Riders or
Endorsements thereto, the Benefit Schedule,
the Individual Enrollment Agreement, the
individual
application,
the
Subscriber’s
identification card, health statements, and all
individual applications to HPN for healthcare
benefits.
“HPN Reimbursement Schedule” means the
schedule showing the amount the Plan will pay
for Eligible Medical Expenses. It is based upon:
•
•
•
the amount usually paid to the Provider; or
the amount paid to other Providers with the
same or similar qualifications; or
the relative value and worth of the service
compared to other services which the Plan
determines to be similar in complexity and
nature with reference to other industry and
governmental sources.
“Preexisting Condition” means any Illness or
Injury, or any related condition to an Illness or
Injury for which medical advice, diagnosis, care
or treatment was recommended or received
during the six (6) months immediately
preceding the enrollment date of coverage
under this Agreement. This term does not
include genetic information in the absence of a
diagnosis of the condition related to such
information nor does it include Complications
of Pregnancy, newborns, newly adopted
children and coverage for enteral formulas and
special food products.
“Medically Necessary” means a service or
supply needed to improve a specific health
condition or to preserve the Member’s health
and which, as determined by HPN is:
ƒ Consistent with the diagnosis and treatment
of the Member’s Illness or Injury;
ƒ The most appropriate level of service which
can be safely provided to the Member; and
ƒ Not solely for the convenience of the
Member, the Provider(s) or Hospital.
“Primary Care Physician” or “PCP” means a
Plan Provider who has an independent
contractor agreement with HPN to assume
responsibility for arranging and coordinating the
delivery of Covered Services to Members. A
PCP’s agreement with HPN may terminate. In
the event that a Member’s PCP agreement
terminates, the Member will be required to select
another PCP.
In determining whether a service or supply is
Medically
Necessary,
HPN
may
give
consideration to any or all of the following:
ƒ The likelihood of a certain service or supply
producing a significant positive outcome;
ƒ Reports in peer-review literature;
ƒ Evidence based reports and guidelines
published
by
nationally
recognized
professional organizations that include
supporting scientific data;
ƒ Professional standards of safety and
effectiveness that are generally recognized
in the United States for diagnosis, care or
treatment;
ƒ The opinions of independent expert
Physicians in the health specialty involved
when such opinions are based on broad
professional consensus; or
ƒ Other relevant information obtained by HPN.
“Prior Authorization” means a system that
requires a Provider to get approval from the Plan
before providing non-emergency healthcare
services to a Member for those services to be
considered Covered Services.
“Tier II Expanded Plan Provider Benefits”
means those benefits for services received
from an HPN Plan Provider from HPN’s
expanded list of Providers, after satisfaction of
a Calendar Year Deductible and subject to the
Member’s Coinsurance percentages, and/or
Copayments, in some instances.
Certain
Covered Services require Prior Authorization
from HPN’s Managed Care Program in order
for the Member to receive maximum benefits.
When applied to Inpatient services, “Medically
Necessary” further means that the Member’s
condition requires treatment in a Hospital rather
than in any other setting.
Services and
Form No. HPN-DisSum-DAP3- 2005
“Tier III Non-Plan Provider Benefits” means
those benefits for services received from a Tier
III Non-Plan Provider after satisfaction of the
6
Leg102\NV 2005\Individual\Form #
Calendar Year Deductible and subject to the
Member’s Coinsurance percentage. Certain
Covered Services require Prior Authorization
from HPN’s Managed Care Program in order
for the Member to receive maximum benefits.
Member will be required to submit claim forms
and itemized bills for services rendered.
If you have any questions about your benefits or
provider information, call the Member Services
Department at (702) 242-7300 or 1-800-7771840.
Form No. HPN-DisSum- DAP3- 2005
7
Leg102\NV 2005\Individual\Form #
Health Plan of Nevada, Inc.
$10/$35/$60 Individual Prescription Drug Benefit
Summary
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
$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
Tier I:
Preferred Generic Covered Drug
*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
Health Plan of Nevada, Inc.
$10/$35/$60
Resumen de los beneficios individuales de
medicamentos con receta
Éste es un resumen de sus beneficios de medicamentos con receta y copagos dentro del Anexo de Beneficios de medicamentos con
prescripción médica del Health Plan of Nevada (HPN). Es posible conseguir una lista completa de los Medicamentos cubiertos
genéricos preferidos llamando al Departamento de Servicios al Miembro al teléfono (702) 242-7300 o 1-800-777-1840. Si desea
más información, visite nuestro sitio web www.healthplanofnevada.com. Los asegurados pagarán el copago más bajo cuando sus
Proveedores le receten Medicamentos cubiertos genéricos preferidos.
Términos del plan utilizados comúnmente
Medicamentos cubiertos
Todas las recetas deben incluir Medicamentos cubiertos con el fin de que el Plan realice los pagos correspondientes. Los
Medicamentos cubiertos son aquellos que se obtienen mediante receta, que están aprobados por la FDA, que expida un farmacólogo
registrado, que recete un Proveedor del Plan y que no estén excluidos por el Plan. Los beneficios para algunos de los Medicamentos
cubiertos médicamente necesarios requieren autorización previa de HPN Si esos Medicamentos Cubiertos se suministran sin
autorización previa, no es un beneficio cubierto.
Farmacias del Plan
El Asegurado tiene acceso a las sucursales locales de las cadenas de farmacias reconocidas en todo el país. Las Farmacias del Plan
están incluidas en el Directorio de Proveedores de HPN. Las recetas deberán surtirse en Farmacias del Plan para que se paguen los
beneficios, a no ser que se hayan surtido en caso de emergencia o por algún problema urgente.
Medicamentos de mantenimiento
Algunos Medicamentos de mantenimiento preferidos pueden ser sujetos de una Provisión de mantenimiento de hasta 90 días.
Este beneficio le permite al Asegurado aprovechar nuestro programa de surtido de recetas por Encomienda postal que le permite
economizar dinero. Entre los ejemplos de Medicamentos de mantenimiento preferidos se incluyen aquellos que se utilizan para tratar
enfermedades crónicas, riesgosas o prolongadas como la diabetes, las cardiopatías, la hipertensión y la artritis.
Farmacia minorista perteneciente al Plan
Nivel I: Medicamento cubierto genérico preferido
Copago de $10 por Provisión terapéutica de hasta 30 días
Nivel II: Medicamento cubierto preferido de marca*
Copago de $35 por Provisión terapéutica de hasta 30 días
Nivel III: Medicamento genérico no preferido o
Medicamento cubierto de marca*
Copago de $60 por Provisión terapéutica de hasta 30 días
*Si se tiene disponible un medicamento genérico equivalente cubierto, el Miembro paga el copago de medicamentos
cubiertos de Beneficios I más la diferencia entre el EME** del medicamento cubierto genérico y el EME del medicamento
cubierto de marca a la Farmacia dentro del plan para cada suministro terapéutico.
Farmacia por Encomienda Postal Perteneciente al Plan
Medicamentos de mantenimiento cubiertos preferidos
El Miembro paga dos (2) de los copagos aplicables, según se
indicó anteriormente por una Provisión de mantenimiento de
hasta 90 días por Medicamentos de mantenimiento cubiertos
preferidos. Los beneficios para recetas por encomienda postal se
encuentran disponibles a través de la farmacia de encomienda
postal contratada por HPN.
**EME (Gastos médicos elegibles) se refiere al costo para el Plan por el Medicamento cubierto y que fue contratado con
la farmacia de la red. Los beneficios por medicamentos que se expiden con receta médica están sujetos a Exclusiones y
limitaciones adicionales que se muestran en la Cláusula adicional de beneficios de medicamentos bajo receta, Formulario No.
HPN-NV-Ind-3TierSIO-2006, en el Certificado de Cobertura de HPN, Lista de beneficios Anexo A y cualesquier otras Cláusulas
aplicables. Se pueden solicitar copias de estos documentos. Los documentos del Plan serán los que rijan cuando se trate de resolver
cualquier pregunta sobre beneficios o pagos. Este es un resumen de los medicamentos cubiertos que se expiden con receta médica.
PD-4428