Health Plan of Nevada, Inc. - MyHPN Silver 12
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$0 Copay
100% Coinsurance
Specialist Visit
$15 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$0 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
$0 Copay
100% Coinsurance
Laboratory Outpatient and Professional Services
$0 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
$0 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
10% Coinsurance
100% Coinsurance
Generic Drugs
$25 Copay
100% Coinsurance
Preferred Brand Drugs
$75 Copay
100% Coinsurance
Non-Preferred Brand Drugs
$100 Copay
100% Coinsurance
Specialty drugs
50% Coinsurance
100% Coinsurance
Outpatient Facility Fee
10% Coinsurance
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
10% Coinsurance
100% Coinsurance
Emergency Room Services
$500 Copay
$500 Copay
Emergency Transportation/Ambulance
10% Coinsurance
100% Coinsurance
Urgent Care
$50 Copay
100% Coinsurance
Inpatient Hospital Services
10% Coinsurance
100% Coinsurance
Inpatient Physician and Surgical Services
10% Coinsurance
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$0 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
10% Coinsurance
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$0 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
10% Coinsurance
100% Coinsurance
Prenatal and postnatal care
$0 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
10% Coinsurance
100% Coinsurance
Home Healthcare Services
$0 Copay
100% Coinsurance
Outpatient Rehabilitation Services
$0 Copay
100% Coinsurance
Habilitation Services
10% Coinsurance
100% Coinsurance
Skilled Nursing Facility
10% Coinsurance
100% Coinsurance
Durable Medical Equipment
$150 Copay
50% Coinsurance
50% Coinsurance
100% Coinsurance
Hospice Services
10% Coinsurance
100% Coinsurance
Chiropractic Care
$0 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
10% Coinsurance
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
10% Coinsurance
100% Coinsurance
Well Baby Visits and Care
$0 Copay
100% Coinsurance
Allergy Testing
$0 Copay
100% Coinsurance
Diabetes Education
$0 Copay
100% Coinsurance
Nutritional Counseling
$0 Copay
100% Coinsurance
Eye Exam for Children
$0 Copay
100% Coinsurance
Eye Glasses for Children
$0 Copay
100% Coinsurance
Accidental Dental
$500 Copay
$500 Copay
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered