1 Administration Application – Faxes



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BENEFIT TRANSMITTAL SHEET – NVMED02

NEVADA PUBLIC EMPLOYEES’ BENEFITS PROGRAM

CONFIDENTIAL

IMPORTANT: THE ATTACHED IS THE HealthSCOPE BENEFITS COVERAGE INFORMATION YOU REQUESTED. THIS MESSAGE AND ANY ATTACHMENTS ARE INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU ARE NOT THE INTENDED RECIPIENT, PLEASE NOTIFY THE SENDER BY REPLYING TO THIS MESSAGE, AND THEN DELETE IT FROM YOUR SYSTEM. THANK YOU.

THIS INFORMATION IS BEING PROVIDED TO YOU AT YOUR REQUEST AND IS BEING DISCLOSED BY HealthSCOPE BENEFITS TO FACILITATE THE TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS IN CONNECTION WITH MEMBER.

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BENEFIT COVERAGE INFORMATION

Verification of coverage or eligibility is not a guarantee of benefits. All claims are subject to review in accordance with the plan's provisions, limitations and exclusions.

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|BENEFIT INFORMATION |

|Networks:  |

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|PEBP’s Statewide PPO Network is administered by Hometown Health and Sierra Health Care Options. |

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|Aetna is the National Medical Network available to CDHP Participants who reside outside of Nevada or who live in Nevada but choose to seek health care |

|outside of Nevada |

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|Network Type: PPO (Preferred Provider Organization). No referral required. |

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|Precertification Vendor: HTH Healthcare: 888-323-1461 |

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|Drug Vendor: Express Scripts: 855-889-7708 |

|COVERED SERVICE/PLAN CATEGORY |IN-NETWORK |OUT-OF-NETWORK |

|GENERAL INFORMATION |

|Deductible |Employee only - $1,500 |Employee only - $1,500 |

| |Family - $3,000 |Family - $3,000 |

|Out-of-Pocket Limit |Employee only: $3,900 |Employee only: $10,600 |

| |Family: $7,800 |Family: $21,200 |

|Lifetime Maximum Benefit |Unlimited |

|COVERED SERVICES |

|Abortion Services |80% after deductible |50% after deductible |

| |Employee and Spouse only covered |

| |Covered only if the mother’s life is endangered |

|Acupuncture & Acupressure Services |80% after deductible |50% after deductible |

| |Letter of medical necessity required after 15 visits per plan year |

| |Covered only when performed by a licensed MD, DO, Acupuncturist or Oriental Medical Doctor (OMD) |

| |Maintenance services are not covered |

|Allergy Testing |80% after deductible |50% after deductible |

|Precert required | | |

|Allergy Injections & Serum |80% after deductible |50% after deductible |

|Allergy Office Visits |80% after deductible |50% after deductible |

|Ambulance Services |80% after deductible |80% after deductible |

|Ground or Air | | |

| |Medically necessary transportation to the nearest appropriate facility only |

| |Ambulance services will be reviewed for medical necessity and the usual, customary and reasonable amount of |

| |charges. |

| |Precert required for Scheduled Air Transportation between facilities – Group utilizes REMSA |

|Ambulatory Surgical Facility |80% after deductible |50% after deductible |

|Precert required | | |

|Anesthesiologist Services |80% after deductible |50% after deductible |

|Biofeedback |80% after deductible |50% after deductible |

| |Not covered for Mental Health/Substance Abuse |

|Birthing Center |80% after deductible |50% after deductible |

|Birth Control |100% no deductible |50% after deductible |

|Birth Control Office Visit |100% no deductible |50% after deductible |

|Female patients | | |

|Vasectomy |80% after deductible |50% after deductible |

|Cardiac Rehabilitation |80% after deductible |50% after deductible |

| |Must be ordered by a Physician |

| |Phase 1 and 2 only covered |

|Chemotherapy |80% after deductible |50% after deductible |

|Precert required | | |

|Chiropractic Services |80% after deductible |50% after deductible |

| |Maintenance services are not covered |Maintenance services are not covered |

| |Letter of medical necessity required after 15 visits per plan year |

|Cochlear Devices |80% after deductible |50% after deductible |

|Precert required | | |

|Dental Services – Accident |80% after deductible |50% after deductible |

| |Services must begin within 90 days of the accident and be completed within 12 months |

|Dental Services – Non Accident |80% after deductible |50% after deductible |

|Diabetes Management |80% after deductible |Not covered |

|Diagnostic Lab |80% after deductible |50% after deductible |

|Facility | | |

|Diagnostic Radiology |80% after deductible |50% after deductible |

|Facility | | |

|Durable Medical Equipment |80% after deductible |50% after deductible |

|Precert required if cost exceeds $1,000 | | |

|Education Services |80% after deductible |Not covered |

|Emergency Room |80% after deductible |80% after deductible |

|Gender Dysphoria / Gender Reassignment |80% after deductible |50% after deductible |

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| |Contact Customer Service for full benefit description |

| |Limited to one (1) Gender Reassignment Surgery in the individual’s lifetime while covered under PEBP CDHP |

| |Precert required for all services related to Gender Dysphoria (excluding mental health services) |

|Genetic Testing & Counseling |80% after deductible |50% after deductible |

|Precert required | | |

|Hearing Exams & Hearing Aids |50% after deductible |50% after deductible |

|Group utilizes Amplifon hearing aid | | |

|concierge vendor | | |

| |Hearing Aids are limited to $1,500 per hearing aid (per ear, every three years) after the plan year deductible |

|Hemodialysis |80% after deductible |50% after deductible |

|Precert required – inpatient, outpatient | | |

|and home dialysis | | |

|Home Health Care Services |80% after deductible |50% after deductible |

|Home dialysis requires precert | | |

| |60 visits per plan year |

|Hospice Services |80% after deductible |80% after deductible |

| |Respite care not covered |

|Hospital (Inpatient) |80% after deductible |50% after deductible |

|Precert required, including Observation | | |

|stays exceeding 24 hours | | |

|Hospital (Outpatient) |80% after deductible |50% after deductible |

|Surgery | | |

|Precert required | | |

|Hospital (Outpatient) |80% after deductible |50% after deductible |

|Non surgical/routine | | |

|Sexual Dysfunction Treatment |80% after deductible |50% after deductible |

|Infertility Services |80% after deductible |50% after deductible |

| |Diagnosis only covered for Employee and Spouse |

| |Treatment not covered |

|Infusion Therapy |80% after deductible |50% after deductible |

| |Home Infusion therapy included in Home Health maximum, 60 visits per benefit period |

|Maternity Services |Preventative prenatal – 100% no deductible |50% after deductible |

| |All other services - 80% after deductible | |

| |Preventative prenatal services covered for all covered female members |

| |Delivery & Post Partum care covered for Employee & Spouse only |

| |Dependent daughter delivery not covered except for complications of the pregnancy |

|Massage Therapy |Not covered |Not covered |

|Medical and Surgical Supplies |80% after deductible |50% after deductible |

|Mental Health & Substance Abuse |80% after deductible |50% after deductible |

|Inpatient | | |

|Precert required | | |

| |Partial & Day Treatment are considered inpatient.  Precert required |

|Mental Health & Substance Abuse |80% after deductible |50% after deductible |

|Outpatient | | |

|Obesity Care Management (OCM) Program |100% no deductible |Not covered |

| |Contact Customer Service for full benefit description |

|Bariatric Surgery |80% after deductible | 50% after deductible |

|Precert required | | |

| |Limited to ONE obesity related surgical procedure PER LIFETIME |

| |Contact Customer Service for full benefit description |

|Outpatient Occupational Therapy |80% after deductible |50% after deductible |

| |Must be ordered by a Physician |

|Orthotics (back, neck, knee, wrist, etc.)|80% after deductible |50% after deductible |

|Orthopedic Shoes and Foot Orthotics |80% after deductible |50% after deductible |

|Outpatient Physical Therapy |80% after deductible |50% after deductible |

| |Must be ordered by a Physician |

|Physician Office Visits for Non-Routine |80% after deductible |50% after deductible |

|Care | | |

| | | |

|Telemedicine |Medical visit: |

|Doctors on Demand |$40 per visit |

| | |

| |Psychologist visit: |

| |$50 for 25 minutes |

| |$95 for 50 minutes |

|Physician Visits During Inpatient |80% after deductible |50% after deductible |

|Hospital/SNF Confinement | | |

|Podiatry Services |80% after deductible |50% after deductible |

|Private Duty Nursing Services |80% after deductible |50% after deductible |

|Prosthetic Appliances |80% after deductible |50% after deductible |

|Precert required if cost exceeds $1,000 | | |

|Respiratory Therapy |80% after deductible |50% after deductible |

|Routine – Health Maintenance |100% no deductible |**Not covered |

|All ages | | |

|Well Woman Care |100% no deductible |Not covered |

|PCP or OB/GYN setting | | |

|Radiation Therapy |80% after deductible |50% after deductible |

|Routine Nursery Care of Newborn Infant |80% after deductible |50% after deductible |

|Second and Third Surgical Opinion |80% after deductible |50% after deductible |

|Skilled Nursing Facility |80% after deductible |50% after deductible |

|Precert required | | |

| |60 days per condition per benefit period |

| |Covered for mental health and substance abuse |

|Sleep Disorders |80% after deductible |50% after deductible |

| |Oral appliances not covered |

|Outpatient Speech Therapy |80% after deductible |50% after deductible |

| |Must be ordered by a Physician |

|Surgeon |80% after deductible |50% after deductible |

|TMJ Treatment |50% after deductible |50% after deductible |

|Precert required | | |

| |Temporomandibular joint (TMJ) services are payable when medically necessary but not if treatment is recognized as |

| |a dental procedure, involves extraction of teeth or application of orthodontic devices (e.g., braces) or splints. |

|Transplants |80% after deductible |50% after deductible |

|Precert required | | |

| |Non experimental procedures only |

| |Surgery must be performed at a Center of Excellence (COE), determined by HTH and HSB |

|Urgent Care Facility |80% after deductible |50% after deductible |

|Facility – 456, 516, 526 | | |

|Physician – place of service 20 | | |

|Vision Services |$25 copay then 100% no deductible up to $120 maximum per plan year |

|Routine | |

| |Participant will be responsible for the $25 copay at the time of service |

| |1 routine vision exam per benefit period – covered at the In Network level whether provider is participating or |

| |not. |

| |Exam only. Hardware not covered |

| |Vision/ophthalmological  CPT’s S0620, S0621, 99172, 99173, 99174 covered under preventative at 100% no deductible |

| |after applicable copayRefractions covered 92015 covered |

| |Refractions conducted with an examination with a medical diagnosis will be paid under the medical benefit and |

| |subject to deductible and coinsurance  |

| |All other Vision/ophthalmological CPT’s beginning with 92* will be processed as non-routine at ded/coins |

|Vision Services |80% after deductible |50% after deductible |

|Medical Condition | | |

| |Covers first pair of contacts or glasses only when following cataract surgery |

| |$120 limit on one set of lenses (contacts or frame) following cataract surgery or treatment of glaucoma. |

|Wigs |80% after deductible |80% after deductible |

| |Covered if hair loss due to chemotherapy/radiation |

|Payor ID: 71063 | |

|Claims Mailing Address: | |

|HealthSCOPE Benefits | |

|PO Box 91603 | |

|Lubbock, TX 79490-1603 | |

| | |

|Do you need help understanding this form? |Please call HealthSCOPE Benefits Customer Service at 888-7NEVADA or 888-763-8232 |

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