Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined and explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members.  Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.  We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. 

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2025 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2024 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined to a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health.  We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot covert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about obtaining health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace guaranteed issue individual coverage in your state. For assistance in finding coverage, please contact us at 877-545-7378 or visit our website at www.shophpn.com/exchange.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an Identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 877-545-7378 or write to us at Health Plan of Nevada, Inc., P.O. Box 15645, Las Vegas, NV 89114-5645. You may also request replacement cards through our website at www.healthplanofnevada.com and log into the Online Member Center.

You obtain care from "Plan providers" and "Plan facilities".  You will only pay copayments and/or coinsurance, and you will not have to file claims.

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members.  Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law.  We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically.  The list is also on our website.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area. 

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.  

This plan provides Case Management for complex conditions and can be reached 877-545-7378 for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update periodically.  The list is also on our website. This plan provides Care Coordinators for complex conditions and can be reached 877-545-7378 or www.healthplanofnevada.com for assistance.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care. This plan has a provider directory, which we urge you to review before choosing your primary care provider.

Your primary care provider can be a family practitioner, pediatrician, or internist who practices as a primary care provider. Women may also select an Obstetrician/Gynecologist. Your primary care provider will provide most of your healthcare or give you a referral to see a specialist.

If you want to change primary care providers or if your primary care provider leaves the Plan, call us. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, women may see their Obstetrician/Gynecologist without a referral.

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will work with the Plan and your specialist to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.
  
  Your primary care provider will create your treatment plan. The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist.
  
  If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  
  - terminate our contract with your specialist for other than cause;
  
  - drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  
  - reduce our service area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 877-545-7378. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your Plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

It is best to contact your primary care provider before you seek any services.

Contact Customer Service at 877-545-7378 for additional details.

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care provider has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:

• Transplants (including Plan paid transportation, lodging & meals)
• All non-emergency hospital admissions
• Admissions to skilled nursing facilities and inpatient hospice facilities
• All non-emergency inpatient and outpatient surgeries
• Non-preventive routine lab and x-ray services
• Anti-cancer drug therapy, non-cancer related drug therapy or other medically necessary therapeutic drug services
• Dialysis
• Therapeutic radiology
• Complex allergy diagnostic services (including RAST) and serum injections
• Otologic evaluations
• Other complex diagnostic imaging services, including CT scan and MRI; vascular diagnostic and therapeutic services; pulmonary diagnostic services; and complex neurological testing
• Positron Emission Tomography (PET) scans
• Courses of treatment, including allergy testing or treatment, angioplasty, physiotherapy or manual manipulation
• Physical, occupational and speech therapy
• Hearing Aids
• Home Healthcare Services
• Prosthetic devices, orthotic devices and durable medical equipment
• Certain prescription drugs
• Pharmaceutical compounds that exceed $50
• Genetic disease testing
• Clinical trials or studies for the treatment of cancer or chronic fatigue syndrome
• Dental anesthesia for enrolled dependent children when determined to be medically necessary
• Non-emergency (ground or air) transport
• All elective inpatient and non-routine outpatient non-emergency mental health, severe mental illness, and substance related services, including intensive outpatient program treatment, electroconvulsive treatment, and psychological and neuropsychological testing.
• Gender Reassignment Surgery
• Infertility Services

First, your provider, your hospital, you, or your representative, must call us at 877-545-7378 before admission or services requiring prior authorizations are rendered.

Next, provide the following information:

• enrollee's name and Plan identification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the provider and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgement of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information, or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 877-545-7378. You may also call OPM's Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 877-545-7378. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

You do not need precertification of a maternity admission for a routine delivery.  However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note:  When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim

A non-network facility admission would not be covered unless a medical emergency occurred (see Section 5(d) for what to do in case of emergency).

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.  In that case, we will make all reasonable efforts to provide you with the necessary care.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call 877-545-7378.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to: 

1.  Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or 

2.   Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care provider, you pay a $10 copayment per office visit, and when admitted to the hospital, you pay a $300 copayment per admission.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for costs associated for the treatment of temporomandibular joint pain dysfunction syndrome.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your out-of-pocket expenses (copayments and coinsurance) total $3,500 for Self Only, or $7,000 for a Self Plus One and Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $3,500 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $3,500 Self Only maximum out-of-pocket limit and a $7,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $3,500 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $7,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $3,500 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• amounts charged for non-covered services
• amounts exceeding applicable plan benefit maximums or eligible medical expenses payments
• amounts charged for services requiring prior authorization if not obtained
• amounts charged for services of non-plan providers, except in the case of emergency services or for other covered services provided by a non-plan provider that are prior authorized by HPN's Managed Care Program

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to the plan's catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan's catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year's benefits; benefit changes are effective January 1. 

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

In addition, your health plan adopts and complies with the surprise billing laws of Nevada and NSA AB469.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.uhcfeds.com or contact the health plan at 877-545-7378.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26). 
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In provider's office 

$10 per office visit for Primary Care

$25 per office visit for Specialist

• At home

• In an urgent care center

$30 per visit

Primary care services

• In a convenient care center
• By a physician extender or assistant

Note: Convenient care centers provide treatment for minor injuries and illnesses.

Note: Physician extenders or assistants are health care providers who are not physicians but who perform medical activities typically performed by a physician; most commonly a nurse practitioner or physician assistant.

$5 per visit

• During a hospital stay
• In a skilled nursing facility
• Second surgical opinion

NowClinic

Note: For non-life threatening and non-urgent medical conditions, connect virtually with a provider 24/7 by accessing NowClinic (a contracted telemedicine provider) from your computer or mobile device.

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• EKG
• Non-routine mammograms
• Ultrasounds

Note: See Section 3, You need prior Plan approval for certain services.

• Complex diagnostic imaging services, such as nuclear medicine, CT scan, cardiac ultrasonography, MRI and arthrography
• Complex vascular diagnostic and therapeutic services including Holter monitoring, treadmill stress testing, and impedance venous plethysmography
• Complex neurological diagnostic services including EEG, EMG, and evoked potential
• Complex pulmonary diagnostic services including pulmonary function testing and apnea monitoring
• Otologic evaluation
• Abdominal aortic aneurysm screening, one screening for men between the ages of 65 and 75 with a history of smoking

Note: See Section 3, You need prior Plan approval for certain services.

• Genetic disease testing

Note: We only cover genetic disease testing when we preauthorize the services. Ask us to authorize your genetic disease testing before you begin services. We will only cover genetic disease testing that we determine is medically necessary.

• Positron Emission Tomography (PET) scan

Routine physical every 12 months

The following preventive services are covered at the time interval recommended at each of the links below.

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at
  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at
  https://www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to
  https://health.gov/myhealthfinder

• Routine mammogram

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.  For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments and coinsurance.

• Routine exams limited to: 
• One routine eye exam every 12 months
• One routine hearing exam every 12 months 

Note:  Coverage is provided for vision and hearing exams only when required to diagnose illness or injury.  Office visit copay applies.

Not covered:

• Physical exams required for obtaining or continuing employment, licensing, or insurance; attending schools or camp; athletic exams; travel; or adoption purposes.
• Exams or treatment ordered by a court, or in connection with legal proceedings.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to
  https://brightfutures.aap.org.
• Children’s immunizations endorsed by the Centers for Disease Control (CDC) including Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the at
  https://www.cdc.gov/vaccines/schedules/index.html.
• You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, and coinsurance. 

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, [carrier list what therapy is covered and frequency of visits]
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity. 
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

Note: Also see Section 5(h) [Carriers who offer nutritional and physical activity support for members can also state additional optional programs under Wellness and Other Special Features Section 5(h) and insert a cross reference to this Section 5(a)].

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes 
• Prenatal and Postpartum care
• Delivery
• Screening and counseling for prenatal and postpartum depression

Nothing for prenatal care or the first postpartum care visit;  $10 per office visit for all postpartum care visits thereafter.

$25 for inpatient professional delivery services.

Breastfeeding and lactation support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to pre-certify your vaginal delivery; see page 30 for other circumstances, such as extended stays for you and your baby. 
• You may remain in the hospital for up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.  
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.  In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes: 

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms 

Note:  See additional Family Planning and Prescription drug coverage Section 5(f).  

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA- supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Nothing

Voluntary male sterilization

$10 per office visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling, except as indicated in Lab, X-ray, and other diagnostic tests

Infertility is defined as: A disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.  It is defined by the failure to achieve a successful pregnancy after 12 months or more of unprotected intercourse or artificial insemination for individuals under age 35.  Evaluation and treatment for those individuals actively looking to achieve a conception may be justified based on medical history and diagnostic testing, and is warranted after six (6) months for individuals age 35 years or older.

Artificial insemination

Diagnosis and treatment of infertility such as:

• Intravaginal Insemination (IVI)
• Intracervical Insemination (ICI)
• Intrauterine Insemination (IUI)

Coverage is provided for up to 6 cycles per member annually.

 Note:  Prior Authorization is required.

50% of EME

Fertility drugs (See Section 5f)

Fertility drugs (See Section 5f)

Not covered:

• Infertility services after voluntary sterilization 
• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete, intra fallopian transfer (GIFT) and zygote intra fallopian transfer (ZIFT)
  • Cost of donor sperm
  • Cost of donor egg

All charges

• Testing and treatment
• Allergy injections

Allergy serum

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note:  High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on pages 40-44.

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note:  Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 18.

• Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 30 sessions.

Note: Cardiac rehabilitation services must be provided on a monitored basis.

$10 per office visit

• Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

Note: For members under the age of 18 or, if enrolled in high school, until such member reaches the age of 22. ABA for the treatment of autism is limited to 250 visits, not to exceed 1,500 total hours of therapy per member per calendar year.

Not covered:

• Sports medicine treatment intended to primarily improve athletic ability

All charges

Rehabilitation and Habilitative Services

Sixty (60) days/visits per year for the services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note:  We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Note:  Prior authorization is required.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Alternative treatments, such as acupuncture, hypnosis, biofeedback

Rehabilitation and Habilitative Services from a speech therapist

Sixty (60) days/visits per calendar year.

$10 per visit

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note:  For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children

• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note:  For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

Not covered: 

• Hearing services that are not shown as covered

• Annual eye refraction

$10 per office visit

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

Not covered:

• Eye examination required as a condition of employment or by a government body
• Low vision aids
• Orthoptics or vision training and exercises
• Any surgical procedure for the improvement of vision when vision can be made adequate through the use of glasses or contact lenses

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above.
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery).

• Artificial limbs and eyes
• Braces which include only rigid and semi-rigid devices used for supporting a weak or deformed body member or restricting or eliminating motion of a diseased or injured part of the body
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Terminal devices, such as hand or hook
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Implanted hearing-related devices, such as bone achored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
• Foot orthotics when part of a lower body brace
• Podiatric shoe inserts when prescribed for a diabetic condition, otherwise only when an integral part of a lower body brace
• Lumbosacral supports
• Adjustments of an initial Prosthetic or Orthotic device required by wear or by change in patient's condition when ordered by a Plan provider

 Note:  For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

50% of EME, not to exceed $200 per device

External hearing aids

Note: Benefit coverage is limited to a single purchase of a type of hearing aid, including repair and replacement once every three (3) years.      

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cops
• Special shoe accessories or corrective shoes unless they are an integral part of a lower body brace
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than three years after the last one we covered

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Traction equipment

Note:  Call us at 877-545-7378 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Note:  Wheelchairs are limited to coverage of a single standard manual wheelchair as deemed medically necessary and appropriate.

Note:  Blood glucose monitors for diabetes are covered under Section 5(f) prescription drug benefit.

Note:  Prior authorization is required.

• Insulin pumps

• Insulin pump supplies

$10 per 30-day therapeutic supply

Not covered:

• Motorized wheelchairs
• Custom wheelchairs
• More than one piece of equipment serving essentially the same function except for replacements as authorized by the Plan.  Coverage for alternate or spare equipment is not provided.

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or a home health aide on an intermittent basis.
• Services include oxygen therapy, intravenous therapy and medications.
• Services include physical therapy, speech therapy, and occupational therapy by licensed therapists.
• Medical and surgical supplies that are customarily furnished by the Home Health Care agency or program.
• Prescribed drugs furnished and charged for by the Home Health Care agency or program. Prescribed drugs under this provision do not include self-injectable prescription drugs.

Note: Home health aide services furnished to member only when receiving nursing services therapy.

Note:  Prior authorization is required.

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Housekeeping or meal service

• Manual manipulation of the spine (except for reductions of fractures or dislocations) and extremities

Adjunctive procedures such as ultrasound and electrical muscle stimulation if they meet medical necessity requirements

Not covered:

• Vibration therapy
• Cold pack applications

All charges

• Medical treatment in a Phase I, II, III or IV clinical trial or study for the treatment of cancer conducted in the state of Nevada
• Medical treatment in a Phase II, III or IV clinical trial or study for the treatment of chronic fatigue syndrome conducted in the state of Nevada

Note:  Medical treatment must be provided by a contracted provider participating in an appropriately approved clinical trial (listed in https://clinicaltrials.gov/).

Services must be provided by an HPN provider. In the event an HPN provider does not offer a clinical trial with the same protocol as the one the member's Plan provider recommended, the member may select a non-plan provider performing a clinical trial with that protocol within the state of Nevada. If there is no provider offering the clinical trial with the same protocol as the one the member's Plan provider recommended in Nevada, the member may select a clinical trial outside of Nevada but within the United States of America.

Note:  See the Prescription Drug Benefits, Section 5(f) for coverage of drugs and medications.

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback
• Acupuncture
• Any portion of the clinical trial or study that is customarily paid for by the government, biotechnical, pharmaceutical or medical industry
• Services that are specifically excluded from coverage under this Plan regardless of whether such services are provided under the clinical trial or study
• Expenses related to participation in the clinical trial or study including, but not limited to; travel, housing and other expenses
• Expenses incurred by a person who accompanies a member during the clinical trial or study
• 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
• Extra care costs related to taking part in a clinical trial such as additional tests that are not part of the patient's routine care
• Research costs related to conducting a clinical trial such as research physician and nurse time, analysis of results and clinical tests performed only for research purposes

Coverage is provided for:

• Tobacco Cessation program comprised of a 12-week evidence-based support group led by a Licensed Alcohol & Drug Counselor (LADC). The program includes 1:1 counseling in addition to group sessions and may include medication or nicotine replacement therapy.  Member may continue attending support groups past 12 weeks.  Call 702-877-5356 to register.

Note: See Prescription Drug Benefits, Section 5(f) for coverage of tobacco cessation medication.

Nothing for counseling for up to two (2) quit attempts per year, including one (1) individual counseling session and at least six (6) group counseling sessions per quit attempt.

Nothing for (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self-management:
  • Comprehensive diabetes management program include working with a registered nurse specializing in diabetes to receive personalized education and support to learn how to best self-manage their diabetes.  Topics covered during weekly phone calls include healthy eating, medication management, blood sugar monitoring, and exercise.  Adult type 1 diabetes support also provided by a Certified Diabetes Care and Education Specialist.  Opportunity provided to members to attend a comprehensive diabetes class taught by a Registered Dietitian. 

    To schedule an appointment call 702-242-7346.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus (see Reconstructive surgery)
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices (see Orthopedic and prosthetic devices for device coverage information)
• Treatment of burns

Note: For female surgical family planning procedures see Family Planning Section 5(a).

Note: For male surgical family planning procedures see Family Planning Section 5(a).

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker.

$25 per surgery

• Surgically implanted contraceptives

• Surgical treatment of severe obesity (bariatric surgery)

Note: 

• Individuals must have a body mass index (BMI) of greater than 40 kg/m2, or greater than 35kg/m2 with significant co-morbidities such as cardiac disease, diabetes, hypertension, or diseases of the endocrine system, e.g., Cushing's syndrome, hypothyroidism, or disorders of the pituitary or adrenal glands.
• Individuals must show documentation that medically supervised weight loss therapy for 6 consecutive months within the last 24 months has been ineffective.
• Individuals must be age 18 or over and have a psychological/psychiatric evaluation by a licensed practitioner with a recommendation for gastric restrictive surgery.
• Covered services rendered in the treatment of complications in connection with gastric restrictive surgery.
• Contact the Plan at 877-545-7378 for additional eligibility criteria.

• Surgical Assistant Services

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member's appearance; and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.  Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birthmarks, webbed fingers, and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses and surgical bras and replacements [see Prosthetic devices, Section 5(a)]

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

• Gender Affirming Surgery
  • Provided as any other Medically Necessary service under this Plan (as appropriate to each patient) including:
  • Male to Female:
    • Clitoroplasty (creation of clitoris)
    • Labiaplasty (creation of labia)
    • Orchiectomy (removal of testicles)
    • Penectomy (removal of penis)
    • Urethroplasty (reconstruction of female urethra)
    • Vaginoplasty (creation of vagina)
    • Breast enlargement including augmentation mammaplasty and breast implants
    • Thyroid cartilage reduction/reduction thyroid chondroplasty
    • Trachea shave (removal or reduction of the Adam’s apple)
    • Voice modification surgery (e.g., laryngoplasty, glottoplasty or shortening of vocal cords)
    • Voice lessons and/or voice therapy
    • Facial gender affirming surgeries
  • Female to Male:
    • Bilateral mastectomy or breast reduction
    • Hysterectomy (removal of uterus)
    • Metoidioplasty (creation of penis, using clitoris)
    • Penile prosthesis
    • Phalloplasty (creation of penis)
    • Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
    • Scrotoplasty (creation of scrotum)
    • Testicular prosthesis
    • Urethroplasty (reconstruction of male urethra)
    • Vaginectomy (removal of vagina)
    • Vulvectomy (removal of vulva)
    • Voice modification surgery (e.g., laryngoplasty, glottoplasty or shortening of vocal cords)
    • Voice lessons and/or voice therapy
    • Facial gender affirming surgeries

Note:  The Member must meet all of the following eligibility qualifications for genital surgery, surgery to change secondary sex characteristics and bilateral mastectomy or breast reduction surgery (in addition to the overall eligibility requirements in the EOC).

• Breast Surgery - The Member must provide documentation in the form of a written psychological assessment from at least one qualified behavioral health provider experienced in treating Gender Dysphoria. The assessment must document that the Member meets all of the following criteria:
• Has persistent, well-documented Gender Dysphoria;
  • Has the capacity to make a fully informed decision and to consent for treatment;and
  • If significant medical or mental health concerns are present, they must be reasonably well controlled.
• Genital Surgery - The Member must provide documentation in the form of a written psychological assessment from at least two qualified behavioral health providers experienced in treating Gender Dysphoria, who have independently assessed the Member. The assessment must document that the Member meets all of the following criteria:
  • Has persistent, well-documented Gender Dysphoria;
  • Has the Capacity to make a fully informed decision and to consent for treatment; 
  • If significant medical or mental health concerns are present, they must be reasonably well controlled;
  • Complete at least 12 months of successful continuous full-time real-life experience in the desired gender; and
  • Complete 12 months of continuous cross-sex hormone therapy appropriate for the desired gender (unless medically contraindicated).
  • Travel and lodging costs incurred for gender affirming reconstructive surgeries will be allowed up to $2,000 annually.

HPN makes no representation or warranty as to the medical competence or ability of any Gender Dysphoria Treatment Center/Facility or its respective staff or Physicians. HPN shall have no liability or responsibility, either direct, indirect, vicarious or otherwise, or any actions or inactions, whether negligent or otherwise, on the part of any Gender Dysphoria Treatment Center/Facility or its respective staff or Physicians.

$25 per surgery

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Treatment of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth
• Removal of teeth necessary in order to perform radiation therapy
• Removal of stones from salivary ducts
• Other surgical procedures that do not involve the teeth or their supporting structures

• Treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Shortening of the mandible or maxillae for cosmetic purposes

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under "You need prior Plan approval for certain services" on page 18 for prior authorization procedures. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy only for patients with chronic pancreatitis)
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestines
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung:  Single, bilateral or lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
• AL Amyloidosis
• Multiple myeloma (de novo and treated)
• Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants
The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia  
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced neuroblastoma
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
• Hemoglobinopathy
• Infantile malignant osteopetrosis
• Kostmann's syndrome
• Leukocyte adhesion deficiencies
• Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
• Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfilippo's syndrome, Maroteaux-Lamy syndrome variants)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Phagocytic/Hemophagocytic deficiency disease (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• X-linked lymphoproliferative syndrome
• Autologous transplants for
• Acute lymphyocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin's lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
• Amyloidosis
• Aggressive non-Hodgkin lymphomas
• Breast cancer
• Epithelial ovarian cancer
• Ewing's sarcoma
• Medulloblastoma
• Multiple myeloma
• Neuroblastoma
• Pineoblastoma
• Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

$25 per surgery

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Neuroblastoma

$25 per surgery

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan's medical director in accordance with the Plan's protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
• Beta Thalassemia Major
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
• Acute lymphyocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin's lymphoma
• Advanced non-Hodgkin's lymphoma
• Chronic lymphocytic leukemia
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Myeloproliferative disorders (MDDs)
• Mylelodysplasia/Myelodysplastic syndromes
• Ovarian cancer
• Sickle cell anemia
• Autologous transplants for
• Advanced childhood kidney cancers
• Advanced Ewing sarcoma
• Advanced Hodgkin's lymphoma
• Advanced non-Hodgkin's lymphoma
• Aggressive non-Hodgkin lymphomas
• Breast Cancer
• Childhood rhabdomyosarcoma 
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial Ovarian cancer
• Mantle Cell (non-Hodgkin's lymphoma)

Note:  We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for bone marrow/stem cell transplants for up to 4 potential donors whether family or non family.

National Transplant Program (NTP) - OptumHealth Care Solutions (URN) used for organ tissue transplant in addition to the facilities that are directly contracted with the health plan for this service.

You pay 20% of EME

• Transportation, lodging and meals

Note:  Prior authorization is required.  

All costs exceeding $200 per day; $10,000 per transplant period.

•  Organ procurement

•  Retransplantation services

All costs exceeding 50% of EME

Not covered:

• Donor screening tests and donor search expenses, except as indicated on this page
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in:

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Physician's office

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$300 per admission

Other hospital services and supplies, such as:

• Operating, recovery, maternity and other treatment rooms
• Prescribed drugs and medications
• Clinical pathology and laboratory services and supplies and X-rays
• Dressing, splints, casts, and sterile tray services
• Medical supplies including oxygen and its administration
• Blood or blood plasma, if not donated or replaced
• Intravenous injections and solutions
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

See section 5(b) Surgical and anesthesia services.

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes and schools, including room and board at therapeutic boarding schools
• Personal comfort items, such as telephone, television, barber services, guest meals, and beds
• Private nursing care, except when medically necessary

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Clinical pathology and laboratory services and supplies and X-rays
• Dressing, splints, casts, and sterile tray services
• Medical supplies including oxygen and its administration
• Blood or blood plasma, if donated or replaced
• Pre-surgical testing
• Intravenous injections and solutions
• Anesthetics and anesthesia service

$50 per visit

See section 5(b) Surgical and anesthesia services.

Not covered:

• Blood and blood derivatives not replaced by the member.
• Dental procedures

All charges

Skilled nursing facility (SNF):

• Bed, board, and general nursing care
• Prescribed drugs and medications
• Clinical pathology and laboratory services and supplies and X-rays
• Dressing, splints, casts, and sterile tray services
• Oxygen and its administration
• Blood or blood plasma, if not donated or replaced
• Pre-surgical testing
• Intravenous injections and solutions

Note:  Maximum benefit of 100 days per member per calendar year. 

Note:  Prior authorization is required.

Not covered:

• Custodial care

Supportive and palliative care for terminally ill members are covered in the home or in a hospice facility. Covered services include:

• Inpatient hospice services
• Inpatient respite services

Note:  Inpatient and Outpatient respite services are limited to a combined maximum benefit of 5 Inpatient days or 5 Outpatient visits per member per 90 days of Hospice Care.

Note: Prior authorization is required.

• Outpatient hospice

• Outpatient respite services

Note:  Inpatient and Outpatient respite services are limited to a combined maximum benefit of 5 Inpatient days or 5 Outpatient visits per member per 90 days of Hospice Care.

• Bereavement services

Note:  Bereavement services provided to the member's family after death are limited to five (5) group therapy sessions per event. Treatment must be completed within six (6) months of the date of death.

Not covered:

• Independent nursing
• Homemaker services

No Benefits

• Local professional ambulance service when medically appropriate

• Emergency air ambulance

• Non-emergency (ground or air) transport

• Emergency care at a doctor's office

$10 per office visit for Primary Care

$25 per office visit for Specialist

• Emergency care at an urgent care facility

• Emergency care in a hospital emergency room

Note:  We waive the ER copay if you are admitted to the hospital.

$150 per visit

Not covered:  Elective care or non-emergency care

All charges

• Emergency care at a doctor's office

$10 per office visit for Primary Care

$25 per office visit for Specialist

• Emergency care at a non-Plan urgent care facility

• Emergency care in a hospital emergency room

Note:  We waive the ER copay if you are admitted to the hospital.

$150 per visit

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

• Professional ambulance service when medically appropriate

Note: See Section 5(c) for non-emergency service.  Non-emergency (ground or air) transport requires prior authorization.

• Emergency air ambulance

Note:  Ambulance services will be reviewed on a retrospective basis to determine medical necessity. The member will be fully liable for the cost of ambulance services that are not medically necessary.

$250 per trip

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

Note: Prior authorization is required for intensive outpatient program treatment, electroconvulsive therapy treatment, and psychological and neuropsychological testing.

Not covered:

• Mental health services and substance-related and addictive disorder services performed in connection with conditions not listed in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or conditions listed as "Other Conditions" that may be of focus of clinical attention.
• Outside of an initial assessment, mental health and substance-related and addictive disorder services as treatments for a primary diagnosis of conditions and problems that may be a focus of clinical attention, but are specifically noted not to be mental disorders within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
• Outside of an initial assessment, treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, pyromania, kleptomania, personality disorders (with the exception of dialectical behavior therapy for borderline personality disorders) and paraphilic disorder.
• Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction, and learning.
• Tuition for services that are school-based for children and adolescents required to be provided by, or paid for by, the school under the Individuals with Disabilities Education Act.
• Outside of an initial assessment, unspecified disorders for which the provider is not obligated to provide the clinical rationale as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
• Hypnosis.
• Milieu therapy, biofeedback treatment, behavior modifications, sensitivity training, hydrotherapy, electrohypnosis, electrosleep therapy, electronarcosis, narcosynthesis, rolffing, vocational rehabilitation and wilderness programs.

All charges

• Outpatient diagnostic tests provided and billed by a licensed mental health and/or substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Not covered:

• Mental health services and substance-related and addictive disorder services performed in connection with conditions not listed in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or conditions listed as "Other Conditions" that may be of focus of clinical attention.
• Neuropsychological testing when not required for the diagnosis of a mental illness, substance use disorder, or developmental disability.
• Tuition for services that are school-based for children and adolescents required to be provided by, or paid for by, the school under the Individuals with Disabilities Education Act.

All charges

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization or facility-based intensive outpatient treatment

We cover the following medications and supplies prescribed by a provider and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Drugs for sexual dysfunction
• Drugs to treat gender dysphoria
• Oral contraceptive drugs
• Growth hormone therapy
• Self-injectable drugs
• Pediatric and prenatal vitamins, except those listed under preventive care medications
  
• Medications prescribed to treat obesity

Note: Preferred sexual dysfunction drugs are limited to 15 pills/tablets per therapeutic supply and require prior authorization by the Plan. Contact the Plan for details.

Note: We only cover Growth Hormone Therapy (GHT) when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 18.

Note: A "self-injectable" is to be administered subcutaneously or intramuscularly and does not require administration by a licensed practitioner.

Note: Supplies, such as sharps containers, needles, syringes, and tubing necessary to administer an injectable specialty drug available at no cost.

Note:  Multiple drugs can be used in the treatment of gender dysphoria including the simple sex hormones such as estrogen/progestin and testosterone.  Other agents such as leuprolide are involved in adjusting the body’s production of sex hormones and are often used in the treatment of gender euphoria.  HPN covers treatments for gender dysphoria that are supported for use by the FDA or clinical compendia.

Tier 1 = $7 per therapeutic supply; mail order = $14 

Tier 2 = $35 per therapeutic supply; mail order = $70

Tier 3 = $55 per therapeutic supply; mail order = $110

Tier 4 = $100 per therapeutic supply; mail order = $200

Note: You pay two applicable copayments for a 90-day therapeutic supply of maintenance medication obtained through our mail order program.

• Diabetic supplies, including:
  • disposable needles and syringes for the administration of covered medications 
  • urine checking reagents   
  • blood glucose measuring strips (Contour Next)

$35 per 30-day therapeutic supply

• Diabetic supplies, including:
  • blood glucose measuring strips (OneTouch)
  • lancet strips

$7 per 30-day therapeutic supply

• Diabetic equipment, including:
  • blood glucose monitors (OneTouch)
  • lancet device

$7 per unit

Tobacco cessation drugs (e.g., nicotine patches)

Nothing.  Limited to 2 quit attempts per year.

Drugs for infertility

Drugs associated with any IVF procedures will be covered up to 3 cycles of medical annually.

Drugs associated with artificial insemination (IUI, IVI, ICI) procedures will be covered with no limitations.

Covered products include:

Clomiphene

Tier 1 = $7

Endometrin

Follistim

Ganirelix made by Merck/Organon

Tier 2 = $35

Chorionic Gonadotropin

Pregnyl

Progesterone

Novarel

Tier 3 = $55

Ganirelix made by Ferring

Ovidrel

Cetrorelix

Crinone

Gonal-F

Menopur

Fyremadel

Note: FDA dosing limits are applied to coverage to align with covered cycles.

Note: Prior authorization is required.

Tier 4 = $100

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care).  

Any non-covered drugs including contraceptives would require prior authorization.  Members or their providers, on the member's behalf, can fill out and submit the Prior Authorization Request Form available at healthplanofnevada.com.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a).

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Nothing

Compounds, when medically necessary and prior authorized by the Plan

Tier 3 = $55 per therapeutic supply; mail order = $110

Special food products/enteral formulas

• Special food product means a food product specially formulated to have less than one gram of protein per serving intended to be consumed under the direction of a physician. The term does not include food that is naturally low in protein.

Preventive Medications

The following are covered:

Preventive Medications with a USPSTF A and B recommendations.  These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse- recommendations.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a).

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Nonprescription medications
• Anorexic agents
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Drugs and medicine approved by the FDA for experimental or investigational use except when prescribed for the treatment of cancer or chronic fatigue syndrome, or any drug that has been approved by the FDA for less than one (1) year unless prior authorized by HPN.
• Vitamin C nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• General vitamins, except the following which require a prescription order or refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins
• Medical Marijuana
• Prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken, or destroyed.
• Drugs or supplies available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed, unless HPN has designated the over-the-counter medication as eligible for coverage as if it were a prescription drug and it is obtained with a prescription order or refill from a physician. Prescription drugs that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain prescription drugs that HPN has determined are therapeutically equivalent to an over-the-counter drug.
• Any product for which the  primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of illness or injury except for prescription drug products that are enteral formulas prescribed for the treatment of inherited metabolic diseases as defined by state law.
• Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration (FDA) and requires a prescription order or refill. Compounded drugs that are available as a similar commercially available prescription drug.
• A prescription drug that contains an active ingredient(s) which is (are) a modified version of and/or therapeutically equivalent to a covered drug may be excluded as determined by the Plan.
• Covered drugs that are not FDA approved for a specific diagnosis.
• Unit dose packaging of prescription drugs.

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

• Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an injury (not to include chewing) when the treatment starts within the first 10 days after the injury and ends within 60 days, such as:
  • Root canal therapy, post and build-up;
  • Temporary crowns;
  • Temporary partial bridges;
  • Temporary and permanent fillings;
  • Pulpotomy;
  • Extractions of broken teeth;
  • Incision and drainage;
  • Tooth stabilization through splinting.

$25 per visit

• Dental anesthesia for enrolled dependent children

Note: Dental anesthesia is covered only when determined to be medically necessary by a Plan provider and prior authorized by the Plan.

We have no other dental benefits.

All charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue. 
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process. 
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claim process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

It doesn't matter if it's day or night, a holiday or weekend, our free Telephone Advice Nurse Service is open twenty-four (24) hours a day, seven (7) days a week to provide helpful advice on simple medical concerns. Depending on your situation, our Telephone Advice Nurse may help you decide whether to seek urgent care or wait until the next day to see your primary care provider. When you have health questions or concerns, call our Telephone Advice Nurse Service at 800-288-2264.

We have a TTY:/TDD number for use by hearing-impaired members. The TTY:/TDD number is 711.

We offer numerous preventive health management programs to assist members with early detection and prevention of serious illnesses. These programs may include member notifications for childhood immunizations, annual reminders for breast and cervical cancer screenings, educational classes or consults for heart health, smoking cessation, and weight management for adults and children. For information and registration, call 800-720-7253.

We also provide programs to assist those members with chronic conditions to better manage their health. We offer disease management programs for asthma and diabetes.

Day, night and even on holidays, you may access information about your benefits through the Health Plan of Nevada Online Member Center. Take advantage of these convenient service features:

• Change your address
• Request new ID cards
• Verify your coverage for pharmacy services
• Check your copayment amounts for medical services
• Review the status of a claim
• Find out who is on record as your primary care provider (PCP)
• Check status of a prior authorization request

Simply visit us at www.myhpnonline.com.  First time visitors will need to register for a user ID and password.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 877-545-7378, or at our website at www.uhcfeds.com.

When you must file a claim – such as for services you received outside the Plan’s Service Area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number, and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:
Health Plan of Nevada, Inc.
Attn: Claims
P.O. Box 15645
Las Vegas, NV  89114-5645

To submit claims for prescription drugs, contact the plan at 877-545-7378. We will assist you in completing a Direct Member Reimbursement form and help you process your claim.

Submit your claims to:
Health Plan of Nevada, Inc.
Attn: Claims
P.O. Box 15645
Las Vegas, NV  89114-5645

We will notify you of our decision within 30 days after we receive the claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this Brochure.

You may designate an Authorized Representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your Authorized Representative without your express consent. For the purpose of this section, we are also referring to your Authorized Representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of  Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your  Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provide, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a)  Write to us within 6 months from the date of our decision; and

b)  Send your request to us at: Health Plan of Nevada, Inc., P.O. Box 15645, Las Vegas, NV  89114-5645; and

c)  Include a statement about why you believe our initial decision was wrong, based on specific benefit
     provisions in this brochure; and

d)  Include copies of documents that support your claim, such as physicians' letters, operative reports,
     bills, medical records, and Explanation of Benefits (EOB) forms.

e)  Include your email address (optional for members), if you would like to receive our decision via email.
     Please note that by giving us your email address, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a)  Pay the claim or  

b)  Write to you and maintain our denial or

c)  Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within thirty (30) days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, FEHB, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this Brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and Explanation of Benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your Authorized Representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM’s review within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.healthplanofnevada.com

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE is the healthcare program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor.  Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices.  If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment.  If your medical treatment is accepted by the Dept. of Labor Office of Workers' Compensation (OWCP), the provider will be compensated by OWCP.  If your treatment is determined not to be job-related, we will process your benefit according to the terms of this plan, including use of in-network providers.  Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at 877-888-3337, TTY 877-889-5680, you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
• Extra care costs - costs related to taking part in a clinical trial such as additional test that a patient may need as part of the trial, but not as part of the patient's routine care. This Plan does not cover these costs.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 877-545-7378. You may also contact us by fax at (702) 270-6281 or see our website at www.uhcfeds.com.

We waive some costs if the Original Medicare Plan is your primary payor - We will waive some out-of-pocket costs as follows:

• Medical services and supplies provided by physicians and other healthcare professionals.

Please review the following examples which illustrate your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded, conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page 22.

To form or create a medically necessary customized composite drug product by combining two or more different ingredients according to a physician's specifications to meet an individual patient's needs.

Means a facility that provides services for Medically Necessary, non-urgent or non-emergent injuries or illnesses. Examples of such conditions include:

1. diagnostic laboratory services;
2. general health screenings;
3. minor wound treatment and repair;
4. minor illnesses (cold/flu);
5. treatment of burns and sprains, or
6. blood pressure checks.

See Section 4, page 22.

See Section 4, page 22.

Care that is designed essentially to assist individuals in meeting activities of daily living. These include personal care services (help in walking and getting in or out of bed; assistance in bathing, dressing, feeding, and using the toilet; preparation of special diets; and supervision over medication which can usually be self-administered) that do not require the continuing attention of trained medical or paramedical personnel. Custodial care that lasts 90 days or more is sometimes knows as long-term care.

This Plan does not have a deductible.

Charges up to the Plan reimbursement schedule amount, incurred by you while covered under this Plan for covered services. Plan providers have agreed to accept the Plan's reimbursement schedule amount as payment in full for covered services, plus your payment of any applicable copayment. Non-plan providers have not. If you use the services of non-plan providers, you will receive no benefit payments or reimbursement for charges for the service, except in the case of emergency services, urgently needed services, or other covered services provided by a non-plan provider that are prior authorized by the Plan. In no event will the Plan pay more than the applicable Plan reimbursement schedule amount for such services.

This plan regularly evaluates for possible coverage new medical technologies and new applications of existing technologies. New technologies may include medical procedures, drugs and devices. The evaluation process includes a review of information on the proposed service from appropriate government regulatory bodies as well as from published scientific evidence.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Infertility is defined as: A disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.  It is defined by the failure to achieve a successful pregnancy after 12 months or more of unprotected intercourse or artificial insemination for individuals under age 35. 

Evaluation and treatment for those individuals actively looking to achieve a conception may be justified based on medical history and diagnostic testing, and is warranted after six (6) months for individuals age 35 years or older.

A preferred covered drug prescribed to treat certain chronic or life-threatening long-term conditions as determined by the Plan, such as diabetes, arthritis, heart disease, and high blood pressure.

Medical necessity (also "Medically Necessary") means a service is needed to improve a specific health condition or to preserve your health. Medical necessity is present when the Plan determines that the care requested is: consistent with the diagnosis and treatment of your illness or injury; the most appropriate level of service which can be safely provided to you; and not provided solely for your convenience or that of your provider or hospital. When applied to inpatient services, Medically Necessary further means that your condition requires treatment in a hospital rather than any other setting. Services and accommodations are not automatically considered to be Medically Necessary because a physician prescribes them.

The Emergency Health Care Services copayment/benefit level will apply if the member has been placed in an observational bed for the purpose of monitoring the member’s condition, rather than being admitted as an inpatient in the hospital. If the member is admitted to the hospital for observational care then the member will be subject to an inpatient copayment and the emergency room copayment is waived. If the member is not admitted, then the emergency room copayment would apply to the visit.

Means a health care provider who is not a physician (MD/DO) but who performs medical activities typically performed by a physician. It is most commonly a nurse practitioner or physician assistant.

Means the “Eligible Medical Expenses” or the maximum amount HPN will pay for a particular Covered Service as determined by HPN in accordance with HPN’s Reimbursement Schedule.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Certain Covered Services for diagnosis and treatment of low acuity medical conditions delivered to HPN Members through the use of interactive audio, video, or other telecommunications or electronic technology by a contracted HPN Telemedicine Provider listed as such in the HPN Provider Directory at a site other than the site at which the patient is located. Telemedicine is available in all states where HPN contracted Telemedicine Providers offer telemedicine services. Telemedicine does not include the use of standard telephone calls, facsimile transactions or e-mail messaging and is only available through designated providers listed as Telemedicine Providers in the HPN Provider Directory.

The quantity of a covered drug for which benefits are available for a single applicable copayment and may be less than but shall not exceed a 30-day supply.

Us and We refers to Health Plan of Nevada, Inc. or HPN.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 877-545-7378. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Office visit copay:  $10 Primary Care; $25 Specialist

27

$50 per visit

46

$300 per admission

45

$30 per visit at a non-plan urgent care facility

$150 per visit in a hospital emergency room, waived if admitted

49

$30 per visit at urgent care facility

$150 per visit in a hospital emergency room, waived if admitted

48

Regular cost-sharing

50

Tier 1 = Retail $7, Mail order = $14; 

Tier 2 = Retail $35, Mail order = $70; 

Tier 3 = Retail $55, Mail order = $110; 

Tier 4 = Retail $100, Mail order = $200

54

No benefit

58

$10 per visit for one refraction annually and 50% of EME for costs associated with vision supplies

33

Flexible benefits option, Telephone Advice Nurse Service, Services for the deaf and hearing impaired, Preventive Health/Disease Management, We're@YourService

59

Nothing after $3,500/Self Only or $7,000/Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection. 

22