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PLAN COMPARISON
MEDICAL PLAN COMPARISONMedical Plan Comparison
PPO Southern Nevada Northern Nevada
Benefit Category CD PPO HDHP Health Plan of Nevada Hometown Health Plan
Amount you Pay In-
NetworkAmount You Pay In-
NetworkAmount You Pay In-
NetworkMedical deductible $1,500 individual
$3,000 family *$2,600 individual - when two or more family members covered
No Deductible No Deductible
Out-of-pocket maximum $3,900 person $7,800 family (per plan year)
$6,800 person(per calendar year)
$6,200 person $12,400 family (per plan year)
Hospital inpatient 20% coinsurance after deductible
$300 per admission $500 per admission
Outpatient Same Day Surgery
20% coinsurance after deductible
$50 per admission $350 per admission
Primary care visit 20% coinsurance after deductible
$15 copayment $25 copayment
MEDICAL PLAN COMPARISONMedical Plan Comparison
Southern Nevada Northern Nevada
Benefit Category CD PPO HDHP Health Plan of Nevada Hometown Health Plan
Amount you Pay In-
NetworkAmount You Pay In-
NetworkAmount You Pay In-
NetworkSpecialist visit 20% coinsurance after
deductible$25 copayment $45 copayment
Urgent care visit 20% coinsurance after deductible
$30 copayment $50 copayment
Emergency room visit 20% coinsurance after deductible
$150 copayment waived if admitted
$300 copayment per visit
General laboratory services
20% coinsurance after deductible
No charge No charge for outpatient or hospital
Chiropractic services 20% coinsurance after deductible
$15 copayment per visit $45 copayment per visit $1,000 plan year maximum
Wellness/ Prevention No charge for eligible wellness benefits provided in-network
No charge No charge
MEDICAL PLAN COMPARISON
Medical Plan Comparison Southern Nevada Northern Nevada
Benefit Category CD PPO HDHP Health Plan of Nevada Hometown Health Plan
Amount you Pay In-
NetworkAmount You Pay In-
NetworkAmount You Pay In-
NetworkVision Exam Covered under wellness
(Maximum $120Allowance)$10.00 co-payment $15 co-payment
Hardware (frames, lenses, contacts)
No benefit (but can use H.S.A. or H.R.A funds)
$10 copayment/ lenses frames – ($100 allowance) contacts $115 in lieu glasses
15% to 20% discount
PHARMACY PLAN COMPARISONPharmacy Plan Comparison
Southern Nevada Northern Nevada
Benefit Category CD PPO HDHP Health Plan of Nevada Hometown Health Plan
Amount you Pay In-NetworkAmount You Pay In-
NetworkAmount You Pay In-
NetworkPlan Deductible $1,500 individual $3,000 family -
*$2,500 individual - when two or more family members covered
No Deductible No Deductible
Out-of-pocket maximum $3,900 person $7,800 family (per plan year)
Contact HPN for pharmacy OOP Maximum
Contact HHP for pharmacy OOP maximum
Retail Pharmacy - 30 Day SupplyPreferred Generic (Tier 1) 20% after deductible $7 copayment $7 copayment
Preferred Brand (Tier 2) 20% after deductible $35 copayment $40 copayment
Non-Formulary (Tier 3) 100% of contracted price - does not apply to deductible or OOP
$55 copayment Greater of $75 copayment per script or 40%
Specialty Drugs 20% after deductible - available in 30 day supply only through Catamaran Pharmacies
Applicable retail pharmacy copayment will apply
30% coinsurance
PHARMACY PLAN COMPARISON
Pharmacy Plan ComparisonMail Order - 90 Day Supply
PPO Southern Nevada Northern Nevada
Preferred Generic (Tier 1)
20% coinsurance after deductible
$14 copayment $14 copayment
Preferred Brand (Tier 2) 20% coinsurance after deductible
$70 copayment $80 copayment
Non-Formulary (Tier 3) 100% of contracted price - does not apply to deductible or OOP
Not available through mail order
Greater of $150 copayment per script of 40%
Specialty Drugs 20% after deductible - available in 30 day supply only through Catamaran Home Delivery
Applicable retail pharmacy copayment applies
Not available through mail order
MEDICAL PLAN INFORMATION
Information regarding plan benefits, evidence of coverage certificate, prescription drug formulary, and the provider directory for the health insurance plan of your choice is available for review via the following PEBP web links:
• CDHD PPO Plan: http://pebp.state.nv.us/all_plan_benefits.htm
• Health Plan of Nevada (South) : http://www.stateofnvhpnbenefits.com/
• Hometown Health Plan (North): http://stateofnv.hometownhealth.com/