Form No

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MyHPN Solutions

Agreement of Coverage

This Plan may include a Calendar Year Deductible; please refer to the Attachment A Benefit Schedule.

This Agreement of Coverage (AOC) describes your healthcare plan.

Health Plan of Nevada, Inc. (HPN), and the Subscriber have agreed to all of the terms of this AOC. It is part of the contract between

HPN and the Subscriber. This Plan is guaranteed renewable. It may be terminated by HPN or the Subscriber with written notice.

This AOC tells you about your benefits, rights and duties as an HPN Member. It also tells you about HPN’s duties to you. This AOC

including Attachment A Benefit Schedule and any other Attachments, Endorsements, Riders or Amendments to it, your Enrollment

Form, health statements, Member Identification Card and all other applications received by HPN are all part of your HPN membership

package. Please read them carefully and keep them in a safe place. Words that are capitalized are defined in Section 13 –

Glossary.

NOTICE: If upon examination of this Agreement of Coverage you are not satisfied for any reason, you may return the

Agreement of Coverage materials, within ten (10) days of its delivery, and request a full refund of the premium paid.

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Table of Contents

SECTION 1. Eligibility, Enrollment and Effective Date ..................................................................................................... 4

SECTION 2. Termination ...................................................................................................................................................... 6

SECTION 3. Managed Care Program .................................................................................................................................. 7

SECTION 4. Obtaining Covered Services ............................................................................................................................ 9

SECTION 5. Covered Services ............................................................................................................................................ 10

SECTION 6. Exclusions ....................................................................................................................................................... 25

SECTION 7. Limitations ...................................................................................................................................................... 32

SECTION 8. Coordination of Benefits (COB) ................................................................................................................... 33

SECTION 9. Premium Payments, Grace Period and Changes in Premium Rates ......................................................... 35

SECTION 10. General Provisions ....................................................................................................................................... 36

SECTION 11. Pharmacy Provisions ..................................................................................................................................... 40

SECTION 12. Appeals Procedures ....................................................................................................................................... 43

SECTION 13. Glossary .......................................................................................................................................................... 48

Attachment A Benefit Schedule

Attachment B Service Area

Endorsements, if applicable

Riders, if applicable

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The Department of Business and Industry

State of Nevada

Division Of Insurance

Telephone Numbers

for

Consumers of Healthcare

The Division of Insurance (“Division”) has established a telephone service to receive inquiries and complaints from consumers of

healthcare in Nevada concerning healthcare plans.

Hours of operation for the Division:

Monday through Friday from 8 a.m. until 5 p.m., Pacific Time (PT)

The Division is closed during state holidays.

Contact information for the Division:

Carson City Office:

Las Vegas Office:

Phone: (775) 687-0700

Fax: (775) 687-0787

Phone: (702) 486-4009

Fax: (702) 486-4007

1818 East College Pkwy., Suite 103

Carson City, NV 89706

3300 W. Sahara Ave., Suite 275

Las Vegas, NV 89102

The Division also provides a toll-free number for consumers residing outside of the above areas:

1-800-992-0900

Please listen to the greeting and select the appropriate prompt.

If you have any questions regarding your health care coverage, please contact HPN’s Member Services Department at the

following:

Address:

Health Plan of Nevada, Inc.

Attn: Member Services Department

P.O. Box 15645

Las Vegas, NV 89114-5645

Phone:

888-293-6831

(Monday – Friday from 8:00 a.m. until 5:00 p.m., PT)

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SECTION 1. Eligibility, Enrollment and Effective Date

Subscribers and Dependents who meet the following criteria are eligible for coverage under this Plan.

1.1 Who Is Eligible

Subscriber. To be eligible to enroll as a Subscriber, an Individual must:

 Be a United States citizen or national or must be lawfully present in the United States.

 Live in HPN’s Service Area.

 Meet the guidelines established in the Enrollment Application Form.

 Complete and submit to HPN such Enrollment Applications or forms that HPN may reasonably request.

Dependent. To be eligible to enroll as a Dependent, an individual must be one of the following:

 A Subscriber’s legal spouse or a legal spouse for whom a court has ordered coverage.

 A registered domestic partner.

 A child by birth. Adopted child. Stepchild. Minor child for whom a court has ordered coverage. Child being Placed for Adoption

with the Subscriber. A child for whom a court has appointed the Subscriber or the Subscriber’s spouse the legal guardian.

The definition of Dependent is subject to the following conditions and limitations:

 A Dependent includes any child listed above under the limiting age of 26.

 A Dependent does not include anyone who is also enrolled as a Subscriber. No one can be a Dependent of more than one

Subscriber.

 A Dependent includes a Dependent child who is incapable of self-sustaining employment due to mental or physical handicap,

chiefly dependent upon the Subscriber for economic support and maintenance and who has satisfied all of the requirements of (a)

or (b) below:

a. The child must be covered as a Dependent under this Plan before reaching the limiting age, and proof of incapacity and

dependency must be given to HPN by the Subscriber within thirty-one (31) days of the child reaching the limiting age; or

b. The handicap started before the child reached the limiting age, but the Subscriber was covered by another health

insurance carrier that covered the child as a handicapped Dependent prior to the Subscriber applying for coverage with

HPN.

HPN may require proof of continuing incapacity and dependency when the child reaches the limiting age. HPNs determination of

eligibility is final.

Evidence of any court order needed to prove eligibility must be given to HPN.

1.2 Who Is Not Eligible

The following individuals are not eligible for coverage:

 An individual who is eligible and/or enrolled for coverage under Medicare Part A and/or B at the time of application.

 An individual who is eligible and/or enrolled in Medicaid either at the time of application or after enrollment.

 A foster child of the applicant or Subscriber.

 A child placed in the applicant or Subscriber's home other than for adoption.

 A grandchild of the applicant or Subscriber.

 Any other person not defined in Section 1.1.

1.3 Changes In Eligibility Status

It is the Subscriber's responsibility to give HPN written notice, within thirty-one (31) days, of changes which affect his Dependents’

eligibility. Changes include, but are not limited to:

 Reaching the limiting age.

 Ceasing to satisfy the mental or physical handicap requirements.

 Death.

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 Divorce.

 Transfer of residence outside HPN’s Service Area.

 The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health Insurance Program (CHIP). Coverage

will begin only if HPN receive the completed enrollment form and any required premium within sixty (60) days of the date

coverage ended.

 Any other event which affects a Dependent’s eligibility.

If the Subscriber fails to give notice which would have resulted in termination of coverage, HPN shall have the right to terminate

coverage.

A Dependent’s coverage terminates on the same day as the Subscriber.

Continuation of Coverage Due to Specific Change in Eligibility Status.

A Member that becomes ineligible for coverage under this Plan due to specific changes in eligibility status may qualify for the same

rates and coverage under their current HPN Health Benefit Plan under the following circumstances:

 Death of the Subscriber;

 Divorce between Subscriber and spouse;

 Termination of a domestic partnership; or

 When a child involuntarily fails to meet the eligibility rules outlined in Section 1.1.

In order to qualify for continuation of coverage under the above circumstances, the affected Member must contact HPN within thirty-

one (31) days of the date of loss of eligibility to request continued coverage. Any and all waiting periods satisfied under the current

Plan will be credited to the Member under the continued Plan coverage.

1.4 Application

Eligible Individuals and Eligible Family Members must make application to HPN in order to have coverage under this Plan.

1. Newly Eligible Family Members. Any Individual becoming newly eligible as a Dependent may apply for coverage under an

HPN Plan by submitting to HPN the Enrollment Application Form or Membership Change Form within sixty (60) days of the

date on which the individual becomes eligible. A person may become a Newly Eligible Family Member as the result of:

 A change in the Subscriber’s marital or domestic partnership status.

 A birth or adoption of a child by the Subscriber.

 Loss of eligibility with other healthcare coverage.

Enrollment must take place within sixty (60) days of the date of initial eligibility under the circumstances listed above.

2. Right to Deny Application. HPN can deny membership to any person who:

 At application, does not meet the applicable eligibility guidelines.

 Fails to make a premium payment.

 Misrepresents and/or fails to disclose a material fact which would affect coverage under this Plan.

3. Right to Deny Application for Renewal. As a condition of renewal under this Plan, HPN may terminate a Subscriber and/or

Dependent(s) who committed fraud upon HPN or misrepresented a material fact, which affected his coverage under this Plan.

4. Annual Open Enrollment Periods. A Member is eligible to enroll during the Federally Required Open Enrollment Period.

1.5 Effective Date of Coverage

Before coverage can become effective, HPN must receive and accept premium payments and an Enrollment Application Form for the

person applying to be a Member.

1. When the Enrollment Application Form is received, approved and applicable premium payments have been accepted by HPN the

Effective Date is as follows:

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Open Enrollment (2022) -The annual open enrollment period is November 1, 2021 through January 15, 2022; the annual open

enrollment period may be extended at the discretion of the SSHIX.

 Applications received between November 1, 2021 and December 31, 2021 will be effective January 1, 2022.

 Applications received between January 1, 2022 and January 15, 2022 will be effective February 1, 2022.

 Subsequent Open Enrollments (2023 and beyond) – Applications received during the Federally Required Open

Enrollment will be reviewed for an effective date of the 1

of the month following the date the application is received.

2. Subscriber's newborn natural child is covered for the first thirty-one (31) days from birth. Coverage continues after thirty-one

(31) days only if the Subscriber makes application for the child as a Dependent and pays the premium within sixty (60) days of

the date of birth.

3. An adopted child is covered for the first thirty-one (31) days from birth only if the adoption has been legally completed before the

child’s birth. A child Placed for Adoption at any other age is covered for the first thirty-one (31) days following the Placement

for Adoption.

Coverage continues after the applicable thirty-one (31) day period only if the Subscriber makes application for the child as a

Dependent and pays the premium within sixty (60) days after the placement of the child in the Subscriber’s home or the child’s

birth. The coverage of a child Placed for Adoption ends on the date the adoption proceedings are terminated.

4. If a court has ordered the Subscriber to cover his or her legal spouse or unmarried minor child, that person will be covered for the

first thirty-one (31) days following the date of the court order. Coverage continues after thirty-one (31) days if the Subscriber

makes application for the Dependent and pays the Dependent’s premium within sixty (60) days of application. A copy of the

court order must be given to HPN.

Subscriber must give HPN a copy of the certified birth certificate, decree of adoption, or certificate of Placement for Adoption for

coverage to continue after thirty-one (31) days for newborn and adopted children.

Subscriber must give HPN a copy of the certified marriage certificate or any other required documents before coverage can be

effective for other Eligible Family Members.

1.6 Special Enrollment Period (SEP)

An individual may enroll in HPN outside of the annual open enrollment period under the following circumstances; pre-enrollment

verification may apply:

 Loss of Minimum Essential Coverage (MEC): An applicant may enroll sixty (60) days before and after loss of MEC. If

enrolling before loss of MEC, the effective date of coverage will be the date of action of the loss of MEC. If enrolling after

loss of MEC, the effective date will be the first (1

) day the month following loss of MEC. HPN is allowed to reject

enrollment if loss of MEC is due to non-payment of premium.

 Eligible immigration status: A newly eligible applicant may enroll sixty (60) days after gaining eligible immigration status.

Applications received during the month eligible status is obtained will have an effective date of the first (1

) day of following

month, if the Subscriber submits the application by the fifteenth (15

) of the month that immigration status changed.

 Gaining or becoming a Dependent: A new Dependent may be added to the Subscriber’s plan as follows:

 Newborns: Sixty (60) days after birth with date of birth as the effective date;

 Other Dependents Through Marriage: Sixty (60) days after marriage with an effective date of first of the following

month. A new spouse or domestic partner of an existing Subscriber must demonstrate that, for one or more days in

the sixty (60) days preceding the marriage, he/she was either enrolled in MEC or lived in a U.S. Territory or a

foreign country.

 Permanent move: Applicants must provide evidence that a move occurred and, that for one or more days in the 60 days

preceding the move, the applicant was either enrolled in MEC or lived in a U.S. Territory or a foreign country. NOTE:

Moving only for medical treatment and/or staying somewhere for vacation does not qualify as a permanent move.

Verification Delays: Applicants may start their coverage no more than one (1) month later than their effective date would ordinarily

have been, if the special enrollment period verification process delays their enrollment such that they would be required to pay two (2)

or more months of retroactive premium to effectuate coverage or avoid cancellation.

SECTION 2. Termination

HPN may terminate coverage under this Plan at the times shown for any one or more of the following reasons.

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2.1 Termination by HPN

 Failure to maintain eligibility requirements as set forth in Section 1.

 If a Subscriber fails to make premium payments within thirty-one (31) days of the premium due date, coverage will be terminated

on the first day of the month for which a premium was due and not received by HPN.

 With thirty (30) days written notice, if the Member allows his, or any other Member's, HPN ID Card to be used by any other

person, or uses another person's ID Card. The Member will be liable to HPN for all costs incurred as a result of the misuse of the

HPN Member ID Card.

 If the Member performs an act or practice that constitutes fraud, or makes any intentional misrepresentation of material fact, as

prohibited by the terms of coverage, HPN has the right to rescind coverage and declare coverage under the Plan null and void as

follows:

 for a material breach that occurred in the application process, rescission of coverage back to the original Effective Date

of Coverage, with a refund any applicable premium; or

 for any other act of fraud, termination effective no earlier than the date that the fraud had taken place.

Thirty (30) days written notice shall be provided to the Member prior to any rescission of coverage. A Member has the right to

appeal any such rescission.

 Except as specifically provided in Section 1.3, on the last day of the calendar month in which a Member no longer meets the

requirements of Section 1.

 If the Member fails to give written notice within thirty-one (31) days of the loss of eligibility, HPN will terminate coverage

retroactively and refund any corresponding premium.

 When a Subscriber moves his primary residence outside HPN’s Service Area or when a Dependent moves his primary residence

outside HPN's Service Area, Subscriber must notify HPN within thirty-one (31) days of the change.

 When information provided to HPN in the application form is determined to be untrue, inaccurate, or incomplete, in lieu of

termination of coverage. HPN shall have the right to retroactively increase past premium payments to the maximum rate allowed

that would have been billed if such untrue, inaccurate, or incomplete information had not been provided. If the revised premium

rate is not received by HPN within thirty (30) days of the letter of notification, coverage will be terminated as of the paid-to date.

2.2 Termination by the Subscriber

Subscriber has the right to terminate his coverage under the Plan by written notice to HPN. Such termination is effective on the last

day of the month when the notice is received by HPN unless coverage is terminated prior to such date by HPN.

2.3 Reinstatement

Any Plan that has been terminated in any manner may be reinstated by HPN at its sole discretion.

2.4 Effect of Termination

No benefits will be paid under this plan by HPN for services provided after termination of a Member's coverage. The Member will be

responsible for payment of medical services and supplies incurred after the effective date of the termination of this plan.

SECTION 3. Managed Care Program

This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization.

3.1 Managed Care Program

HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees,

and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps

direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner.

3.2 Managed Care Program Requirements

HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. All Plan Providers have agreed to

participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as

payment in full for Covered Services, less the Member’s payment of any applicable Calendar Year Deductible, Copayment or

Coinsurance amount, whereas Non-Plan Providers have not.

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Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or

reimbursement for amounts for any Covered Service, except

 in the case of Emergency Services or Urgently Needed Services; or

 for other Covered Services, as defined in this AOC, provided by a Non-Plan Provider that are Prior Authorized by HPN’s

Managed Care Program.

This includes any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological

facility (x-ray), or any complex diagnostic or therapeutic services. In no event will HPN pay more than the maximum payment

allowance established in the HPN Reimbursement Schedule.

It is the Member's responsibility to verify that the Provider selected is a Plan Provider before receiving any non-Emergency Services

and to comply with all other rules of HPN’s Managed Care Program.

Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure to comply with the rules of HPN’s Managed

Care Program means the Member will be responsible for costs of services received.

3.3 Managed Care Process

The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a

Member to determine:

 If the services are Medically Necessary and/or appropriate.

 The appropriateness of the proposed setting.

 The required duration of treatment or admission.

Following review, HPN will complete the Prior Authorization written notification and send a copy to the Provider and the Member.

The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment.

The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a

Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the

Grievance Review Committee (see Appeals Procedures Section).

3.4 Services Requiring Prior Authorization

All Covered Services not provided by the Member's Primary Care Provider (PCP) require Prior Authorization from the PCP and

HPN’s Managed Care Program. The following Covered Services require Prior Authorization and review through HPN’s Managed

Care Program:

 Non-emergency Inpatient admissions and extensions of stay in a Hospital, Skilled Nursing Facility, Residential Treatment Center

or Hospice.

 Outpatient surgery provided in any setting, including technical and professional services.

 Diagnostic and Therapeutic Services.

 Home Healthcare Services.

 All Inpatient and non-routine Outpatient non-Emergency Mental Health, Severe Mental Illness, and Substance Related and

Addictive Disorder Services, including:

o Intensive outpatient program treatment.

o Outpatient electro-convulsive treatment.

o Psychological testing.

 All Specialist visits or consultations.

 Prosthetic Devices, Orthotic Devices and Durable Medical Equipment.

 Allergy testing or treatment (e.g., skin, RAST); angioplasty; physiotherapy or Manual Manipulation and; habilitative and

rehabilitation therapy (physical, speech, occupational).

3.5 Emergency Admission Notification

The Member must report all emergency admissions to the Member Services Department by calling 888-293-6831 within twenty-four

(24) hours of admission, or as soon as reasonably possible, to authorize continued care.

All emergency admissions are reviewed Retrospectively to determine if the treatment received was Medically Necessary and

appropriate and was for Emergency Services as defined in this AOC. If such Emergency Services are provided by Non-Plan

Providers, all Medically Necessary professional, Inpatient or outpatient Emergency Services will be Covered Services.

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3.6 Appeals Rights

All decisions of HPN’s Managed Care Program may be appealed by the Member through the Appeals Procedure. If an imminent and

serious threat to the health of the Member exists, the appeal will be directed to HPN's Medical Director.

SECTION 4. Obtaining Covered Services

This section tells you under what conditions services are available under this Plan and your obligations as a Member. You should also

carefully review the Exclusions and Limitations Sections (Section 6 and Section 7 respectively) prior to obtaining any healthcare

services.

4.1 Availability of Covered Services

Members are entitled to receive the Covered Services set forth in Section 5 and the Attachment A Benefit Schedule subject to all terms

and conditions of this AOC, and payment of required premium. These Covered Services are available only if and to the extent that

they are:

(a) Provided, prescribed or arranged by the Member's Primary Care Provider (PCP);

(b) Specifically authorized through HPN's Managed Care Program;

(d) Medically Necessary as defined in this AOC.

This section does not apply to Emergency Services or Urgently Needed Services as defined in this AOC, or other Covered Services

provided by a Non-Plan Provider which have otherwise been approved by HPN’s Managed Care Program.

4.2 Agreement of Member

Each Member entitled to receive Covered Services under this Plan agrees to:

 Choose a PCP from the list of available PCPs. The Subscriber and each Dependent may select a different PCP.

 A female Member may choose two (2) PCPs: A general practice Physician and an Obstetrician or Gynecological Physician.

Members may receive benefits only as provided by or approved in advance by the chosen PCP.

 Receive specialty consultation and/or treatment from Plan Physicians only upon written Prior Authorization according to HPN’s

Managed Care Program.

 Obtain Prior Authorization from HPN’s Managed Care Program before receiving any non-Emergency Services from Non-Plan

Providers.

 Be financially responsible for the cost of services in excess of EME, or the Recognized Amount when applicable, when these

services are approved by HPN’s Managed Care Program and received outside of HPN’s Service Area or from Non-Plan

Providers.

 Except in the case of Emergency Services and Urgently Needed Services, be fully responsible for the cost of services not

provided by the PCP according to HPN’s Managed Care Program or Prior Authorized by the PCP or HPN’s Managed Care

Program.

 Provide at least twenty-four (24) hours prior notice of cancellation of an appointment with a Provider.

 Make timely payment of Copayment amounts due to Providers.

4.3 Continuity of Care from Plan Providers

Termination of a Plan Provider’s contract will not release the Provider from treating a Member, except for reasons of medical

incompetence or professional misconduct as determined by HPN.

Coverage provided under this section is available until the latest of the following dates:

 The 120th day following the date the contract was terminated between the Provider and HPN; or

 If the medical condition is pregnancy, the 90th day after the date of delivery or if the pregnancy does not end in delivery, the date

of the end of the pregnancy.

The Member or Plan Provider may submit a request for continuity of care to the address shown below. If the Plan agrees to the

continued treatment, the Plan will pay for Covered Services at the Plan Provider level of benefits for a limited time, as outlined above.

The Plan Provider may not seek payment from the Member for any amounts for which the Member would not be responsible if the

Provider were still a Plan Provider.

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Health Plan of Nevada, Inc.

Attn: Provider Services Dept.

P.O. Box 15645

Las Vegas, NV 89114-5645

888-293-6831

SECTION 5. Covered Services

This section tells you what services and supplies are covered under this Plan. Only services and supplies, which meet HPN’s

definition of Medically Necessary will be considered to be Covered Services. The Attachment A Benefit Schedule shows, if

applicable, the Calendar Year Deductible, Copayments, Coinsurance and benefit limitations for Covered Services. All Covered

Services are subject to HPN’s Managed Care Program.

Ambulance Services

Covered Services include Ambulance Services to the nearest appropriate Hospital. HPN will make direct payment to a Provider of

Ambulance Services if the Provider does not receive payment from any other source. 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.

Assistant Surgical Services

Covered Services include services performed by an assistant surgeon in connection with a covered surgical procedure but only to the

extent surgical assistance is necessary due to the complexity of the procedure involved.

Autism Spectrum Disorder Services

Covered Services include Medically Necessary services that are generally recognized and accepted procedures for screening,

diagnosing and treating Autism Spectrum Disorders for Members under the age of 18 or, if enrolled in high school, until such Member

reaches the age of 22. Covered Services must be provided by a duly licensed physician, psychologist or Behavior Analyst or other

provider that is supervised by the licensed physician, psychologist or behavior analyst and are subject to HPN’s Managed Care

Program. With the exception of the specific limitation on benefits for Applied Behavior Analysis (“ABA”) as outlined in Attachment

A Benefit Schedule, benefits for all Covered Services for the treatment of Autism Spectrum Disorders are payable to the same extent

as other Covered Services and Covered Drugs under the Plan.

Covered Services for the treatment of Autism Spectrum Disorder Services do not include services provided through school services.

Clinical Trial or Study

Covered Services include coverage for Prior Authorized medical treatment received as part of a clinical trial or study if the following

provisions apply:

 The clinical trial or study is conducted in the state of Nevada and the medical treatment is provided:

 In a Phase I, Phase II, Phase III or Phase IV clinical trial or study for the treatment of cancer or other life-threatening disease

or condition;

 In a Phase II, Phase III or Phase IV clinical trial or study for the treatment of chronic fatigue syndrome;

 For cardiovascular disease (cardiac/stroke) which is not life-threatening, for which, as HPN determines, a clinical trial meets

the qualifying clinical trial criteria stated below.

 For surgical musculoskeletal disorders of the spine, hip and knees, which are not life-threatening, for which, as HPN

determines, a clinical trial meets the qualifying clinical trial criteria stated below.

 Other diseases or disorders which are not life-threatening, for which, as HPN determines, a clinical trial meets the qualifying

clinical trial criteria stated below.

 The clinical trial or study is approved by one of the following entities:

 An agency of the National Institutes of Health (NIH) as set forth in 42 U.S.C. § 281 (b);

 The Centers for Disease Control and Prevention (CDC);

 The Agency for Healthcare Research and Quality (AHRQ);

 Centers for Medicare and Medicaid Services (CMS);

 A cooperative group;

 A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center

support grants;

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 The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or

investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health

and Human Services to meet the both of following criteria:

 Comparable to the system of peer review of studies and investigations used by the National Institutes of Health.

 Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome

of the review.

 The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug

Administration;

 The study or investigation is a drug trial that is exempt from having such an investigational new drug application;

 The clinical trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant

institutional review boards (IRBs) before participants are enrolled in the trial. HPN may, at any time, request documentation

about the trial;

 The medical treatment is provided by a duly licensed Provider of healthcare and the facility and personnel have the experience

and training to provide the medical treatment in a capable manner;

 There is no medical treatment available which is considered a more appropriate alternative than the medical treatment provided in

the clinical trial or study;

 There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at

least as effective as any other medical treatment; and

 The Member has signed a statement of consent before his participation in the clinical trial or study indicating that he has been

informed of:

 The procedure to be undertaken;

 Alternative methods of treatment; and

 The risks associated with participation in the clinical trial or study.

Benefit coverage for medical treatment received during a clinical trial or study is limited to the following Covered Services:

 The initial consultation to determine whether the Member is eligible to participate in the clinical trial or study;

 Any drug or device that is approved for sale by the FDA without regard to whether the approved drug or device has been

approved for use in the medical treatment of the Member, if the drug or device is not paid for by the manufacturer, distributor, or

Provider:

 Services normally covered under this Plan that are required as a result of the medical treatment or related complications provided

in the clinical trial or study when not provided by the sponsor of the clinical trial or study;

 Services required for the clinically appropriate monitoring of the Member during the clinical trial or study when not provided by

the sponsor of the clinical trial or study.

Benefits for Covered Services in connection with a clinical trial or study are payable under this Plan to the same extent as any other

Illness or Injury.

Services must be provided by an HPN Plan Provider. In the event an HPN Plan 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. In no event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement

Schedule.

HPN will require a copy of the clinical trial or study certification approval, the Member’s signed statement of consent and any other

materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment.

Corrective Appliances

Corrective Appliances are devices that are designed to support a weakened body part and are manufactured or custom-fitted to an

individual. Covered Services include custom-made or custom-fitted Medically Necessary Corrective Appliances when Prior

Authorized by HPN’s Managed Care Program, to include the following:

 Rigid Cervical Collars;

 Abdominal Binder/Corsets;

 Shoes when prescribed for a diabetic condition, otherwise only when an integral part of a lower body brace;

 Helmets when prescribed in connection with cranial orthosis.

Corrective Appliances do not include:

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 Bionic, myoelectric, microprocessor-controlled, and computerized prosthetics; or

 Deluxe upgrades determined not to be Medically Necessary.

Replacements, repairs and adjustments to Corrective Appliances are Covered Services when required by normal wear and tear or by a

significant change in the Member's condition when ordered by a duly-licensed Provider.

Dental Anesthesia Services

Covered Services include general anesthesia when rendered in a Plan Hospital, Plan outpatient surgical facility, or other duly licensed

Plan facility for an enrolled Dependent child, when such child, in the treating dentist’s opinion and as Prior Authorized by the Plan,

satisfies one or more of the following criteria:

 has a physical, mental or medically compromising condition;

 has dental needs for which local anesthesia is ineffective because of an acute infection, an anatomic anomaly or an allergy;

 is extremely uncooperative, unmanageable or anxious; or

 has sustained extensive orofacial and dental trauma to a degree that would require unconscious sedation.

Coverage for dental anesthesia pursuant to this section is limited to services provided by a Plan anesthesia Provider. Coverage is

provided only during procedures performed by:

 an educationally qualified Specialist in pediatric dentistry; or

 another dentist educationally qualified in a recognized dental specialty for which hospital privileges are granted; or

 who is certified by virtue of completion of an accredited program of post-graduate hospital training to be granted hospital

privileges.

Durable Medical Equipment

All benefits for Durable Medical Equipment (“DME”) includes administration, maintenance and operating costs of such equipment, if

the equipment is Medically Necessary or Prior Authorized. DME includes, but is not limited to:

 Braces;

 Canes;

 Crutches;

 Intermittent positive pressure breathing machine;

 Hospital beds;

 Standard outpatient oxygen delivery systems;

 Traction equipment;

 Walkers;

 Wheelchairs; or

 Any other items that are determined to be Medically Necessary by HPN’s Managed Care Program.

Replacements, repairs and adjustments to DME are limited to normal wear and tear or because of significant change in the Member’s

physical condition.

HPN will not be responsible for the following:

 Non-Medically Necessary optional attachments and modifications to DME for the comfort or convenience of the Member;

 Accessories for portability or travel;

 A second piece of equipment with or without additional accessories that is for the same or similar medical purpose as existing

equipment;

 Home and car remodeling; and

 Replacement of lost or stolen equipment.

Emergency or Urgently Needed Services

Emergency Services obtained from Non-Plan providers will be payable at the same benefit level as would be applied to care received

from Plan Providers.

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Benefits are limited to Eligible Medical Expenses, or the Recognized Amount when applicable, for Non-Plan Provider Emergency

Services as defined under “HPN Reimbursement Schedule”. You are responsible for any Non-Plan Provider Emergency Service

charges that exceed payments made by HPN.

Benefits for Emergency Services are subject to any limit shown in the Attachment A Benefit Schedule.

IMPORTANT NOTE: No benefits are payable for treatment received by a Member in a Hospital emergency room or other

emergency facility for a condition other than an Emergency Service as defined in this AOC.

Examples of conditions which require Medically Necessary treatment, but are not Emergency Services, include:

 Sore throats.

 Flu or fever.

 Earaches.

 Sore or stiff muscles.

 Sprains, strains or minor cuts.

 Suture removal.

 Routine dental services.

 Medication refills.

(a) Within the HPN Service Area. If an Injury or Illness requires Emergency Services, the Member should notify HPN as soon as

reasonably possible after the onset of the emergency.

HPN will review the use of the emergency room Retrospectively for appropriateness and to determine if the Covered Services

received were Medically Necessary. Benefits for such services are payable if the services are determined to have been

Emergency Services, as defined in this AOC.

1. Non-Plan Providers. If Emergency Services are provided by Non-Plan Providers, all Medically Necessary professional

services and Inpatient or outpatient Hospital services will be covered subject to the other terms of this AOC.

The Member should, at the earliest time reasonably possible, notify his PCP after the onset of an emergency.

2. Payment. Benefits for Emergency or Urgently Needed Services received from Non-Plan Providers are limited to the Eligible

Medical Expenses, or the Recognized Amount when applicable, for care required before the Member can safely receive

services from his PCP.

3. Follow-Up Care. In order for benefits to be payable, the Member’s PCP must provide follow-up care, unless authorized by

HPN’s Managed Care Program.

(b) Outside the HPN Service Area. Covered Services received while outside the HPN Service Area are limited to Emergency

Services and Urgently Needed Services when care is required immediately and unexpectedly.

The Member should notify HPN as soon as reasonably possible after the onset of the emergency medical condition. Elective or

specialized care will not be covered if the circumstances leading to the need for such care could have been foreseen before leaving

HPN’s Service Area.

1. Payment. Benefits are limited to the EME, or the Recognized Amount when applicable, for such Covered Services. In

addition, benefits for such services are not payable unless the Covered Services are determined to be Urgently Needed

Services or Emergency Services as defined in this AOC.

2. Follow-Up Care. Continuing or follow-up treatment for Injury or Illness is limited to care required before the Member can

safely return to HPN’s Service Area.

Once the Member is stabilized, benefits for continuing or follow-up treatment are provided only in HPN’s Service Area,

subject to all provisions of this AOC.

24/7 Advice Nurse: If you are feeling ill and are not sure about where you should go to obtain care or do not know whom to call, you

may call the 24/7 Advice Nurse for help. A nurse is available twenty-four (24) hours a day, seven (7) days a week at (702) 242-7330,

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or for the hearing-impaired through Relay Nevada’s TDD/TYY at 1-800-326-6888. If you are traveling outside HPN’s Service Area,

you may call toll free for assistance at 1-800-288-2264.

Free Standing Emergency Room Facilities

These facilities are licensed to provide emergency medical care and are physically separate from hospitals. However, unlike hospital-

based emergency rooms, these facilities often do not provide services for critical conditions such as trauma, stroke, and heart attacks;

most do not receive ambulances or have an operating room on site. Please contact the 24/7 Advice Nurse if you have questions on

where to go to obtain the appropriate level of service.

Gastric Restrictive Surgical Services

Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the

following circumstances:

 Have a body mass index (BMI) of greater than or equal to 40kg/m

; or

 Have a BMI between 35.1-39.9 kg/m

with significant co-morbidities; and

 Can provide documented evidence that dietary attempts at weight control are ineffective; and

 Must be at least 18 years old.

Documentation supporting the reasonableness and necessity of Gastric Restrictive Surgical Services is required, including compliant

attendance at a medically supervised weight loss program (within the last twenty-four (24) months) for at least six (6) consecutive

months with documented failure of weight loss. Significant clinical evidence that weight is affecting overall health and is a threat to

life will also be required.

HPN requires that an initial psychological/psychiatric evaluation, resulting in a recommendation for Gastric Restrictive Surgical

Services, be performed prior to review consideration by HPN’s Managed Care Program. HPN may also require participation in a

post-operative group therapy program.

Treatment for complications resulting from Gastric Restrictive Surgical Services will be covered the same as any other illness.

Gender Dysphoria

Covered Services for Gender Dysphoria, a disorder characterized by diagnostic criteria classified in the current edition of the

Diagnostic and Statistical Manual of the American Psychiatric Association, are provided if Prior Authorized and if the following

diagnostic criteria are met:

For Adults and Adolescents:

 A marked incongruence between the Member’s experienced/expressed gender and the Member’s assigned gender, of at least

six months’ duration, as manifested by at least two of the following:

 A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex

characteristics (or in young adolescents, the anticipated secondary sex characteristics).

 A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence

with one’s experienced/expressed gender or in young adolescents, a desire to prevent the development of the

anticipated secondary sex characteristics).

 A strong desire for the primary and/or secondary sex characteristics of the other gender.

 A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

 A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

 A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender

different from one’s assigned gender).

 The condition is associated with clinically significant distress or impairment in social, occupational or other important areas

of functioning.

For Children:

 A marked incongruence between the Member’s experienced/expressed gender and assigned gender, of at least six months’

duration, as manifested by a strong desire to be of the other gender or an insistence that one is the other gender (or some

alternative gender different from one’s assigned gender) and at least five of the following:

 In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned

gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of

typical feminine clothing.

 A strong preference for cross-gender roles in make-believe play or fantasy play.

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 A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.

 A strong preference for playmates of the other gender.

 In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong

avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys,

games and activities.

 A strong dislike of ones’ sexual anatomy.

 A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

 The condition is associated with clinically significant distress or impairment in social, school or other important areas of

functioning.

The following are Gender Dysphoria Covered Services:

 Psychotherapy for Gender Dysphoria and associated co-morbid psychiatric diagnoses.

 Cross-sex hormone therapy is available as follows:

 Oral and injectable therapy, administered by a provider, during an office visit or in an outpatient or inpatient setting.

 Oral and injectable therapy dispensed from a pharmacy as prescribed by a provider.

Puberty suppressing medication is not cross-sex hormone therapy.

 Laboratory Testing: Benefit coverage includes laboratory testing to monitor continuous hormone replacement therapy

provided as any other outpatient diagnostic service under the Plan.

 Genital Surgery and Surgery to Change Secondary Sex Characteristics: 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)

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)

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 AOC).

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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;

 Must be 18 years or older; 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;

 Must 18 years or older;

 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).

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.

Genetic Disease Testing Services

Covered Services include Prior Authorized Medically Necessary Genetic Disease Testing, when:

 such testing is prescribed following the Member’s history, physical examination and pedigree analysis, genetic counseling, and

completion of conventional diagnostic studies, and a definitive diagnosis remains uncertain and a genetic disease diagnosis is

suspected, and;

 the Member displays clinical features, or is at direct risk of inheriting the mutation in question (pre-symptomatic); and

 the result of the test will directly impact the treatment being delivered to the Member.

Healthcare Facility Services

Covered Services include the following accommodations, services and supplies received during an admission to a Hospital,

Ambulatory Surgical Facility, Skilled Nursing Facility, Residential Treatment Center or Hospice Care Facility.

Accommodations:

 Semiprivate (or multibed unit) room, including bed, board, and general nursing care.

 Private room including bed, board, and general nursing care, but only when treatment of the Member's condition requires a

private room. The semiprivate room rate will be allowed toward the private room rate when a Member receives private room

accommodations for any reason other than Medical Necessity.

 Inpatient accommodations provided in connection with the birth of a child shall be provided for a minimum of forty-eight (48)

hours following an uncomplicated vaginal delivery or a minimum of ninety-six (96) hours following an uncomplicated delivery

by cesarean section. This provision does not require a Member to deliver in a Hospital or other healthcare facility or to remain

therein for the minimum number of hours following delivery.

 Intensive care unit (including Cardiac Care Unit), including bed, board, general and special nursing care, and ICU equipment.

 Observation unit, including bed, board, and general nursing care not to exceed twenty-three (23) hours.

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 Nursery charges for newborns. Reimbursement for Covered Services provided by a Non-Plan Provider outside HPN’s Service

Area to a newborn natural child or adopted child is limited to HPN’s Eligible Medical Expenses, or the Recognized Amount when

applicable, for similar Covered Services provided in HPN's Service Area.

Services and Supplies. Covered Services and supplies provided by a Hospital, Ambulatory Surgical Facility, Skilled Nursing Facility,

Residential Treatment Center or Hospice Care Facility include:

 non-surgical Provider visits;

 operating, recovery, and treatment rooms and equipment (Hospital and Ambulatory Surgical Facility only);

 delivery and labor rooms and equipment (Hospital and Ambulatory Surgical Facility only);

 anesthesia materials and anesthesia administration by Hospital staff (Hospital and Ambulatory Surgical Facility only);

 clinical pathology and laboratory services and supplies;

 services and supplies for diagnostic tests required to diagnose Member's Illness, Injury or other conditions but only when charges

for the services and/or supplies are made by the facility (Hospital, Skilled Nursing Facility and Ambulatory Surgical Facility

only);

 drugs consumed at the time and place dispensed which have been approved for general marketing in the United States by the

Food and Drug Administration (FDA);

 dressings, splints, casts and other supplies for medical treatment provided by the Hospital from a central sterile supply

department;

 oxygen and its administration;

 non-replaced blood, blood plasma, blood derivatives, and their administration and processing;

 intravenous injections and solutions;

 private duty nursing;

 supportive services for a Hospice patient's family, including care for the patient which provides a respite from the stresses and

responsibilities that result from the daily care of the patient and bereavement services provided to the family after the death of the

patient (Hospice Care Facility only); and

 Sterilization procedures.

Hearing Aids

Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a

microphone, amplifier and receiver.

Benefits are available for a hearing aid that is required for the correction of a hearing impairment (a reduction in the ability to perceive

sound which may range from slight to complete deafness) and purchased as a result of a written recommendation by a Physician.

Benefits are provided for the hearing aid and for charges for associated fitting and testing.

Benefits under this section do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Service for which

benefits are available under the applicable medical/surgical Covered Services categories in the HPN AOC, only for a Member:

 who is not a candidate for an air-conduction hearing aid; and

 which is used according to U.S. Food and Drug Administration (FDA) approved indications.

Benefits for bilateral bone anchored hearing aids are available to Members who meet the HPN Managed Care Program criteria.

Home Healthcare Services

Covered Services include services given to a Member in his home by a licensed Home Healthcare Provider or an approved Hospital

program for Home Healthcare. Such services are covered when:

 such care is given in place of Inpatient Hospital or Skilled Nursing Facility care and/or;

 the Member is not physically able to obtain Medically Necessary care on an outpatient basis; and/or

 the Member is under the care of a Physician; and/or

 the Member is homebound for medical reasons.

NOTE: The Member is responsible for one cost-share per day per Home Healthcare agency.

Covered Services and supplies provided by a Home Healthcare agency include:

 Professional services of a registered nurse, licensed practical nurse or a licensed vocational nurse on an intermittent basis.

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 Physical therapy, speech therapy and occupational therapy by a licensed therapist.

 Medical and surgical supplies that are customarily furnished by the Home Healthcare agency or program for its patients.

 Prescribed drugs furnished and charged for by the Home Healthcare agency or program. Prescribed drugs under this provision do

not include Specialty Prescription Drugs.

 One (1) medical social service consultation per course of treatment.

 One (1) nutrition consultation by a certified registered dietitian.

 Health aide services furnished to Member only when receiving nursing services or therapy.

Laboratory Services

Covered Services include prescribed diagnostic clinical and anatomic pathological laboratory services and materials when authorized

by a Member's PCP and HPN’s Managed Care Program.

Mastectomy Reconstructive Surgical Services

Covered Services are provided in the same manner and at the same level as those for any other Covered Health Service and as

required by the Women’s Health and Cancer Rights Act of 1998, as follows:

 All stages of reconstruction of the breast on which the mastectomy has been performed;

 Surgery and reconstruction of the other breast to produce a symmetrical appearance;

 Prostheses; and

 Treatment of physical complications of mastectomy, including lymphedema, in a manner determined in consultation with the

attending provider and the patient.

Medical – Physician Services

Covered Services include services which are generally recognized and accepted non-surgical procedures for diagnosing or treating an

Illness or Injury, performed by a Plan Provider in his office, the patient's home, or a licensed healthcare facility. Medical Services

include:

 direct physical examination of the patient;

 examination of some aspect of the patient by means of pathology laboratory or electronic monitoring procedure which is a

generally recognized and accepted procedure for diagnostic or therapeutic purposes in the treatment of an Illness or Injury;

 procedures for prescribing or administering medical treatment;

 treatment of the temporomandibular joint including Medically Necessary dental procedures, such as dental splints;

 anesthesia services;

 Manual Manipulation (except for reductions of fractures or dislocations);

 Family planning services including sterilization procedures; and

 Limited diagnostic and therapeutic infertility services determined to be Medically Necessary by HPN and Prior Authorized by

HPN’s Managed Care Program. In order for the Member to be eligible for infertility benefits, all of the following criteria must be

met. The Member:

 Is a female under age 44.

 Is not able to become pregnant after the following periods of time of regular unprotected intercourse or

therapeutic donor insemination:

o One year, if a female under age 35; or

o Six months, if a female age 35 or older.

 Has infertility not related to voluntary sterilization or to failed reversal of voluntary sterilization.

For the purposes of this benefit, "therapeutic donor insemination" means using a donor sperm sample to enable a female to

become pregnant.

Covered Services do not include those services specifically excluded in the Exclusions section herein, but do include limited:

 Laboratory studies.

 Diagnostic procedures.

 Artificial insemination services, up to six (6) cycles per Member per lifetime.

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Medical Supplies

Medical Supplies are routine expendable supplies that are essential to carry out the course of treatment for an Illness or Injury or are

necessary for the effective use of Durable Medical Equipment. Medical Supplies include but are not limited to the following:

 Catheter and catheter supplies – urinary catheters, drainage bags, irrigation trays;

 Colostomy bags (and other ostomy supplies);

 Dressing/wound care-sterile dressings, ace bandages, sterile gauze and toppers, Kling and Kerlix rolls, Telfa pads, eye pads,

incontinent pads, lamb’s wool pads;

 Elastic stockings; and

 Splints and slings.

Mental Health Services and Severe Mental Illness Services

All benefits are subject to the Utilization Management process through HPN Behavioral Health. Services must be offered in a

treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient

safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general

medical care. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization.

Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care,

medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health

treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Member or

others.

Partial Hospitalization Programs (PHP): A structured ambulatory program that may be freestanding or Hospital-based and provides

services for at least 20 hours per week.

Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for

adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services and active behavioral

health treatment are provided.

Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including

individual and group counseling services.

No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient.

Residential Treatment Center (RTC): a sub-acute facility or acute care facility which delivers twenty-four (24) hours/ seven (7)

days a week assessment, diagnostic services and active behavioral health treatment to Members. The level of care and length of stay,

in a facility with the appropriate licensure level, is authorized through the HPN Managed Care program. NOTE: Transitional Living

services are not covered under RTC and are not a covered benefit.

All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of

all inpatient admissions to the Plan. When these services are provided out of network, the Member is responsible for providing the

notification and relevant information to the Plan. The Member should provide notice of emergent admissions within twenty-four (24)

hours of admission or as soon as reasonably possible given the circumstances. Member may delegate their responsibility to provide

notification to the non-network facility but it is the Member’s responsibility to ensure that the Plan receives notification. Initial

notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination.

All admissions for Emergency Services are reviewed retrospectively to determine if the treatment received was Medically

Necessary and appropriate. If the Member is admitted to a Mental Health or Severe Mental Illness facility for non-emergency

treatment without Prior Authorization, the Member will be responsible for the cost of services received.

Oral Physician Surgical Services

Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following

Oral Physician Surgical Services are Covered Services:

 Treatment for 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.

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 Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries

caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from

the date of Injury. Examples of Covered Services, in such instances, include:

 Root canal therapy, post and build up.

 Temporary crowns.

 Temporary partial bridges.

 Temporary and permanent fillings.

 Pulpotomy.

 Extraction of broken teeth.

 Incision and drainage.

 Tooth stabilization through splinting.

No benefits are provided for removable dental prosthetics, dentures (partial or complete) or subsequent restoration of teeth, including

permanent crowns.

Organ and Tissue Transplant Surgical Services

All Covered Transplant Procedures are subject to the provisions of HPN’s Managed Care Program and all other terms and provisions

of the Plan, including the following:

1. HPN will determine if the Member satisfies HPN’s Medically Necessary criteria before receiving benefits for transplant services.

2. HPN will provide a written Referral for care to a Transplant Facility.

3. If, after Referral, either HPN or the medical staff of the Transplant Facility determines that the Member does not satisfy the

Medically Necessary criteria for the service involved, benefits will be limited to paying for Covered Services provided up to such

determination.

Covered Transplant Procedures include the following services for human-to-human organ or tissue transplants received during a

Transplant Benefit Period on an Inpatient basis due to an Illness or Injury:

 Hospital room and board and medical supplies.

 Diagnosis, treatment, surgery and other Covered Services provided by a Physician.

 Organ and tissue retrieval which includes removing and preserving the donated part.

 Organ procurement.

 Rental of wheel chairs, hospital-type beds and mechanical equipment required to treat respiratory impairment.

 Ambulance services.

 Medication, x-rays and other diagnostic services.

 Laboratory tests.

 Oxygen.

 Surgical dressings and supplies.

 Immunosuppressive drugs.

 Private nursing care by a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.).

 Transportation of the Member and a companion to and from the site of the transplant. If the Member is a minor, transportation of

two (2) persons who travel with the minor is included. Reasonable and necessary lodging and meal costs incurred by such

companions are included. Itemized receipts for these expenses are required. Daily lodging and meal costs will be paid up to the

limit shown in the Attachment A Benefit Schedule. Benefits for all transportation, lodging and meal costs shall not exceed the

maximum shown in the Attachment A Benefit Schedule for transportation, lodging and meals.

HPN makes no representation or warranty as to the medical competence or ability of any Transplant Facility or its respective staff or

Physicians. HPN shall have no liability or responsibility, either direct, indirect, vicarious or otherwise, for any actions or inaction,

whether negligent or otherwise, on the part of any Transplant Facility or its respective staff or Physicians.

HPN shall have no liability or responsibility, either direct, indirect, vicarious or otherwise, in the event a transplant patient is injured

or dies, by whatever cause, while enroute to a Transplant Facility.

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If a Covered Transplant Procedure is not performed as scheduled due to a change in the Member’s medical condition or death, benefits

will be paid for Prior Authorized Eligible Medical Expenses, or the Recognized Amount when applicable, incurred during the

Transplant Benefit Period.

Other Diagnostic and Therapeutic Services

Diagnostic and Therapeutic Covered Services when authorized by a Member's PCP and HPN’s Managed Care Program include the

following:

 anti-cancer drug therapy;

 complex allergy diagnostic services including RAST and allergoimmuno therapy;

 complex diagnostic imaging services including nuclear medicine, computerized axial tomography (CT scan), cardiac

ultrasonography, magnetic resonance imaging (MRI), and arthrography;

 complex neurological diagnostic services including electroencephalograms (EEG), electromyogram (EMG) and evoked potential;

 complex vascular diagnostic and therapeutic services including Holter monitoring, treadmill or stress testing, and impedance

venous plethysmography;

 complex psychological diagnostic testing;

 complex pulmonary diagnostic services including pulmonary function testing and apnea monitoring;

 hemodialysis and peritoneal renal dialysis;

 other Medically Necessary intravenous therapeutic services as approved by HPN, including but not limited to, non-cancer related

intravenous injection therapy;

 otologic evaluations only for the purpose of obtaining information necessary for evaluation of the need for or appropriate type of

medical or surgical treatment for a hearing deficit or a related medical problem;

 Positron Emission Tomography (PET) Scans;

 therapeutic radiology services; and

 treatment of temporomandibular joint disorder.

Different Copayment and/or Coinsurance amounts may apply to these Covered Services. Please refer to your Attachment A Benefit

Schedule.

Pediatric Dental and Vision Services

Covered services are available to enrolled children up to age (19) when authorized by HPN’s Managed Care Program and ends the

first of the month after the Member’s 19

birthday.

Pediatric Vision coverage includes services for:

 Vision Examination;

 Lenses and Frames;

 Contact Lenses;

 Low Vision Exam; and

 Optional Lenses and Treatments.

Pediatric Dental coverage includes:

 Diagnostic and Preventive Services;

 Restorative Services;

 Endodontic Services;

 Periodontic Services;

 Prosthodontic Services;

 Orthodontic Services; and

 Oral Surgery Services.

(For a complete listing of Pediatric Dental Services and the associated limitations, please refer to the Nevada Division of

Insurance website located at . http://doi.nv.gov/Healthcare-Reform/Individuals-Families/Essential-Health-Benefits/.)

Please refer to the HPN Attachment A Benefit Schedule for the associated Member cost share and limitations for Pediatric Dental and

Vision Covered Services.

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Physician Surgical Services – Inpatient and Outpatient

Covered Services include surgical services that are generally recognized and accepted procedures for diagnosing or treating an Illness

or Injury.

Post-Cataract Surgical Services

Covered Services include Medically Necessary services provided for the initial prescription for corrective lenses (eyeglasses or

contact lenses) and frames or intra-ocular lens implants for Post-Cataract Surgical Services.

Contact lenses will be provided if a Member’s visual acuity cannot be corrected to 20/70 in the better eye except for the use of contact

lenses.

Preventive Healthcare Services

Covered Preventive Healthcare Services will be paid at 100% of Eligible Medical Expenses, or the Recognized Amount when

applicable, without application of any Calendar Year Deductible, Copayment and/or Coinsurance when such services are provided by

a Plan Provider.

Covered Services include the following Preventive Healthcare Services in accordance with the recommended schedule outlined in the

HPN Preventive Guidelines included in your member kit or you may access the most current version of these guidelines at any time by

visiting HPN’s web site at https://www.healthplanofnevada.com.

 Evidence based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States

Preventive Services Task Force (“USPSTF”);

 Immunizations

(1)

that have in effect a recommendation from the Advisory Committee on Immunizations Practices of the Centers

for Disease Control and Prevention;

 With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the

comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”); and

 With respect to women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported

by the HRSA, as long as they are not otherwise addressed by the recommendations of the USPSTF.

For a complete list of Preventive Services, including all FDA approved contraceptives, go to http://doi.nv.gov/Healthcare-

Reform/Individuals-Families/Preventive-Care/.

(1)

Certain immunizations may be administered in a Plan pharmacy.

Prosthetic and Orthotic Devices

Covered Services include the following when received in connection with an Illness or Injury and authorized by HPN’s Managed Care

Program:

 Cardiac pacemakers.

 Breast prostheses for post-mastectomy patients.

 Terminal devices (example: hand or hook) and artificial eyes.

 Braces which include only rigid and semi-rigid devices used for supporting a weak or deformed body member or restricting or

eliminating motion in a diseased or injured part of the body.

 Adjustment of an initial Prosthetic or Orthotic Device required by wear or by change in the patient's condition when ordered by a

Plan Provider.

Routine Radiological and Non-Radiological Diagnostic Imaging Services

Covered Services include prescribed routine diagnostic radiological and non-radiological diagnostic imaging services and materials,

including general radiography, fluoroscopy, mammography, and sonography, when authorized by a Member's PCP and HPN’s

Managed Care Program, but only when no charges are made for the same services and/or supplies by a Hospital, Skilled Nursing

Facility, or an Ambulatory Surgery Center.

Self-Management and Treatment of Diabetes

Coverage includes medication, equipment, supplies and appliances that are for the treatment of diabetes. Diabetes includes type I,

type II and gestational diabetes. Covered Services include:

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 supplies, training and education provided to a Member for the care and management of diabetes, after he is initially diagnosed

with diabetes, to include counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;

 supplies, training and education which is necessary as a result of a subsequent diagnosis that indicates a significant change in the

symptoms or condition of the Member and which requires modification of his program of self-management of diabetes; and

 supplies, training and education which is necessary because of the development of new techniques and treatment for diabetes.

Short-Term Habilitation Services – Inpatient and Outpatient

Covered Services are provided for Short-Term Habilitation Services provided for Members with a congenital, genetic, or early

acquired disorder when both of the following conditions are met:

 The treatment is administered by a licensed speech-language pathologist, licensed audiologist, licensed occupational

therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist and

 the initial or continued treatment must be proven and not Experimental, Investigational or Unproven.

HPN will cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living.

Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and

occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or

outpatient settings.

Coverage for Short-Term Habilitation Services does not apply to those services that are solely educational in nature or otherwise paid

under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational

training and residential treatment are not Short-Term Habilitation Services. A service that does not help the Member to meet

functional goals in a treatment plan within a prescribed timeframe is not an Habilitative Service. When the Member reaches his

maximum level of improvement or does not demonstrate continued progress under a treatment plan, a service that was previously

habilitative is no longer habilitative.

HPN may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow us to

substantiate that initial or continued medical treatment is needed and that the Member’s condition is clinically improving as a result of

the Habilitative Service. When the treating provider anticipates that continued treatment is or will be required to permit the Member to

achieve demonstrable progress, HPN may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency,

anticipated duration of treatment, the anticipated goals of treatment, and how frequently the treatment plan will be updated.

Short-Term Habilitation Services that are provided in the Member’s home by a licensed Home Healthcare Provider are covered as

described under the Home Healthcare Services section.

Short-Term Rehabilitation Services – Inpatient and Outpatient

Short-Term Rehabilitation Covered Services therapy includes:

 Speech therapy.

 Occupational therapy.

 Physical therapy on an Inpatient or outpatient basis when ordered by the Member’s PCP and authorized by HPN’s Managed Care

Program.

Benefits for rehabilitation therapy are limited to services given for acute or recently acquired conditions that, in the judgment of the

Member's PCP and HPN’s Managed Care Program, are subject to significant improvement through Short-Term Rehabilitation

therapy.

Covered Services do not include cardiac rehabilitation services provided on a non-monitored basis nor do they include treatment for

intellectual disability.

Special Food Products and Enteral Formulas

Covered Services include enteral formulas and special food product when prescribed by a Physician and authorized by HPN’s

Managed Care Program for treatment of an inherited metabolic disease.

 “Inherited Metabolic Disease” means a disease caused by an inherited abnormality of the body chemistry of a person

characterized by congenital defects or defects arising shortly after birth resulting in deficient metabolism or malabsorption of

amino acid, organic acid, carbohydrate or fat.

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 “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.

Specialty Services, Second and Third Opinions and Consultations

Covered Services include medical services rendered by a Plan Specialist or other duly licensed Plan Provider whose opinion or advice

is requested by a Member’s treating PCP or the Medical Director for further evaluation of an Illness or Injury on an Inpatient or

outpatient basis. All services must be arranged through HPN’s Managed Care Program.

 Second Opinions. When, as a result of an Illness or Injury, a procedure is recommended by a Physician, HPN or the Member

may request a Second Opinion from a Physician qualified to diagnose and treat the specific Illness or Injury.

 Third Opinions. In the event a first and Second Opinion for a Covered Service are in conflict, HPN or the Member may request a

Third Opinion from a Physician qualified to diagnose and treat the specific Illness or Injury.

Benefits are payable for expenses incurred in connection with an authorized Second or Third Opinion whether or not the elective

surgery or Inpatient care is performed. Payment will be subject to all terms of the EOC, except as otherwise provided in this section.

Limitations. No payment will be made for expenses incurred for second or third opinions/consultations in connection with:

1. any services not covered under this Plan, including cosmetic and dental procedures;

2. minor surgical procedures that are routinely performed in a Physician’s office, such as incision and drainage for abscess or

excision of benign lesions; or

3. diagnostic tests ordered in connection with second and third opinions/consultations, unless Prior Authorized by HPN’s Managed

Care Program.

Substance-Related and Addictive Disorder Services

All benefits for Substance-Related and Addictive Disorder Services are subject to the Utilization Management process through HPN

Behavioral Health. Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as

determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the

extent of supportive services and access to general medical care. All non-routine, outpatient Substance-Related and Addictive

Disorder Services require Prior Authorization.

Inpatient Detoxification: A hospital based program which provides twenty-four (24) hours a day, seven (7) days nursing care,

medical monitoring, and physician availability; daily physician visits, assessment, diagnostic services and active behavioral health

treatment services for the purpose of completing a medically safe and appropriate withdrawal from alcohol or other substances.

Outpatient Detoxification: Outpatient Detoxification is comprised of services that are provided in an ambulatory setting for the

purpose of completing a medically safe withdrawal from alcohol or drugs.

Inpatient Rehabilitation: A hospital based program which provides twenty-four (24) hours a day, seven (7) days nursing care,

medical monitoring, and physician availability, daily physician visits, assessment and diagnostic services, and active behavioral health

treatment services for the purpose of initiating the process of assisting a Member with gaining the knowledge and skills needed to

prevent recurrence of a substance-related disorder.

Partial Hospitalization Programs (PHP): A structured ambulatory program that may be freestanding or Hospital-based and

provides services for at least 20 hours per week.

Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for

adults and six (6) hours per week for children/adolescents during which assessment and diagnostic services and active behavioral

health treatment are provided.

Residential Treatment Center (RTC): a sub-acute facility or acute care facility which delivers twenty-four (24) hours/ seven (7)

days a week assessment, diagnostic services and active behavioral health treatment to Members. The level of care and length of stay,

in a facility with the appropriate licensure level, is authorized through the HPN Managed Care program. NOTE: Transitional Living

services are not covered under RTC and are not a covered benefit.

Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including

individual, group, and family counseling services.

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All inpatient Substance-Related and Addictive Disorder Services require Plan notification. Network facilities must provide

notification of all inpatient admissions to the Plan. When these services are provided out of network, the Member is responsible for

providing the notification and relevant information to the Plan. Members should provide notice of emergent admissions within twenty-

four (24) hours of admission or as soon as reasonably possible given the circumstances. Members may delegate their responsibility to

provide notification to the non-network facility but it is the Member’s responsibility to ensure that the Plan receives notification.

Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit

determination.

All admissions for Emergency Services are reviewed Retrospectively to determine if the treatment received was Medically

Necessary and appropriate. If the Member is admitted to a Substance-Related and Addictive Disorder facility for non-

emergency treatment without Prior Authorization, the Member will be responsible for the cost of services received.

Telemedicine Services

Covered Services received through Telemedicine do not require Prior Authorization unless the Covered Service would require Prior

Authorization if provided in person. The Member does not have to establish a relationship with the Telemedicine Provider to receive

services. Telemedicine Services received through a contracted HPN Primary Care or Specialty Care Provider will be subject to the

applicable facility and professional Copayments and/or Coinsurance amount as set forth in Attachment A, Benefit Schedule.

HPN does not require the Provider to demonstrate the necessity to provide services through, or to receive additional certifications or

licenses in, Telemedicine.

HPN will not refuse to provide coverage because of the distant site from which the contracted Telemedicine Provider provides

Covered Services or the originating site at which the Member receives Telemedicine Services. HPN will not require Covered Services

to be provided through Telemedicine as a condition of coverage.

Virtual Visits: Covered Services received through virtual visits do not require Prior Authorization when provided through an HPN

contracted Provider. Refer to the Attachment A, Benefit Schedule for the Member’s Cost-share responsibility. Benefits are available

for urgent, on-demand healthcare delivered through live audio with video conferencing or audio only technology for treatment of

acute but non-emergency medical needs.

SECTION 6. Exclusions

This section tells you what services or supplies are excluded from coverage under this Plan.

6.1 Services or supplies for which coverage is not specifically provided in this AOC, complications resulting from non-Covered

Services or services which are not Medically Necessary, whether or not recommended or provided by a Provider.

6.2 Services not provided, directed, and/or Prior Authorized by a Member’s PCP and HPN’s Managed Care Program, except for

Emergency Services and Urgently Needed Services.

6.3 Medical care received outside HPN’s Service Area without Prior Authorization from HPN’s Managed Care Program if the need

for such services could reasonably have been foreseen prior to leaving HPN’s Service Area.

6.4 Any charges for non-Emergency Services provided outside the United States.

6.5 Foreign language and sign language interpretation services offered by or required to be provided by a Network or out-of-

Network provider.

6.6 Any services provided before the Effective Date or after the termination of this Plan. This includes admission to an Inpatient

facility when the admission began before the Effective Date or extended beyond the termination date of the Plan.

6.7 Services and supplies that are included in the basic hospital charges for room, board and nursing services. Housekeeping or

meal services as part of Home Healthcare. Modifications to a place of residence, including equipment to accommodate

physical handicaps or disabilities.

6.8 Services for a private room when not Medically Necessary services and charges in excess of the average semi-private room and

board rate.

6.9 Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable

under a medical expense payment provision of an automobile insurance policy.

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6.10 Except as otherwise provided in the HPN Attachment A Benefit Schedule, dental or orthodontic splints or dental prostheses, or

any treatment on or to teeth, gums, or jaws and other services customarily provided by a dentist. Charges for dental services in

connection with temporomandibular joint dysfunction are not covered unless they are determined to be Medically Necessary.

Such dental-related services are subject to the limitations shown in the Attachment A Benefit Schedule.

6.11 Except for reconstructive surgery following a mastectomy, cosmetic procedures to improve appearance without restoring a

physical bodily function. Cosmetic procedures include:

 surgery for sagging or extra skin;

 any augmentation or reduction procedures;

 rhinoplasty and associated surgery;

 and any procedures utilizing an implant which does not alter physiologic functions unless Medically Necessary.

Psychological factors (example: for self-image, difficult social or peer relations) do not constitute restoring a physical bodily

function and are not relevant to such determinations.

6.12 The following infertility services and supplies are excluded, in addition to any other infertility services or supplies determined

by HPN not to be Medically Necessary or not Prior Authorized by HPN’s Managed Care Program:

 Advanced reproductive techniques such as embryo transplants, in vitro fertilization, ZIFT procedures, egg retrieval via

laparoscope or needle aspiration, sperm preparation, sperm washing except prior to artificial insemination if required;

 Home pregnancy or ovulation tests;

 Monitoring of ovarian response to stimulants;

 CT or MRI of sella turcica unless elevated prolactin level;

 Evaluation for sterilization reversal;

 Removal of fibroids, uterine septae and polyps;

 Open or laparoscopic resection, fulguration, or removal of endometrial implants; and

 Surgical tube reconstruction.

6.13 Powered and non-powered exoskeleton devices.

6.14 Any separate charges for anesthesia services associated with pain management procedures.

6.15 Services for the treatment of sexual dysfunction or inadequacies, including, but not limited to, impotence and, except as

provided in the Covered Services Gender Dysphoria section, implantation of a penile prosthesis.

6.16 Reversal of surgically performed sterilization or subsequent resterilizations.

6.17 Elective abortions.

6.18 Amniocentesis, except when Medically Necessary under the guidelines of the American College of Obstetrics and Gynecology.

6.19 Third-party physical exams and/or medical services for employment, licensing, insurance, school, camp or adoption purposes.

Immunizations related to foreign travel unless otherwise provided as a required preventive immunization identified by the

USPSTF. Expenses for medical reports, including presentation and preparation. Exams or treatment ordered by a court, or in

connection with legal proceedings are not covered.

6.20 Venipuncture (drawing of blood for laboratory tests).

6.21 Except as provided in the Covered Services Gastric Restrictive Surgical Services section, weight reduction procedures are

excluded. Also excluded are any weight loss programs, whether or not recommended, provided or prescribed by a Physician or

other medical Practitioner.

6.22 Except as provided in the Covered Services Organ and Tissue Transplant Surgical Services section, any human or animal

transplant (organ, tissue, skin, blood, blood transfusions of bone marrow), whether human-to-human or involving a non-human

device, artificial organs, or prostheses.

 Any and all services or supplies treatments, laboratory tests or x-rays received by the donor in connection with the transplant

(including donor search, donor transportation, testing, registry and retrieval costs) and costs related to cadaver or animal

retrieval or maintenance of a donor for such retrieval.

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 Any and all Hospital, Physician, laboratory or x-ray services in any way related to any excluded transplant service, procedure

or treatment.

6.23 Institutional care which is determined by HPN’s Managed Care Program to be for the primary purpose of controlling the

Member’s environment and Custodial Care, domiciliary care, convalescent care (other than Skilled Nursing Care) or rest cures.

6.24 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.

6.25 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.

6.26 Outside of an initial assessment, treatments for the primary diagnoses of learning disabilities, pyromania, kleptomania,

personality disorders (with the exception of dialectical behavior therapy for borderline personality disorders) and paraphilic

disorder.

6.27 Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social

interaction and learning.

6.28 Tuition for or 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.

6.29 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.

6.30 Neuropsychological testing when not required for the diagnosis of a Mental Illness, Substance-Related and Addictive Disorder

Services or developmental disability.

6.31 Except as otherwise provided in the Attachment A Benefit Schedule, vision exams to determine refractive errors of vision and

eyeglasses or contact lenses other than as specifically covered in this Plan. Coverage is provided for vision exams only when

required to diagnose an Illness or Injury. Vision exams are not considered adult preventive vision services.

6.32 Except as otherwise provided in the Attachment A Benefit Schedule, any prescription corrective lenses (eyeglasses or contact

lenses) or frames following Post-Cataract Surgical Service which include, but are not limited to the following:

 Coated lenses;

 Cosmetic contact lenses;

 Costs for lenses and frames in excess of the Plan allowance;

 No-line bifocal or trifocal lenses;

 Oversize lenses;

 Plastic multi-focal lenses;

 Tinted or photochromic lenses;

 Two (2) pairs of lenses and frames in lieu of bifocal lenses and frames; or

 All prescription sunglasses.

6.33 Coverage is provided for hearing exams only when required to diagnose an Illness or Injury. Hearing exams are not considered

adult preventive care services.

6.34 Bone anchored hearing aids are excluded except when both of the following applies:

 The Member is not a candidate for an air-conduction hearing aid; and

 The bone-anchored hearing aid is used according to FDA approved indications.

Repairs and/or replacements for a bone anchored hearing aid, other than for malfunctions, are excluded for Member’s who meet

the above coverage criteria.

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6.35 Ecological or environmental medicine. Use of chelation, orthomolecular substances; use of substances of animal, vegetable,

chemical or mineral origin not specifically approved by the FDA as effective for treatment; electrodiagnosis; Hahnemannian

dilution and succussion; magnetically energized geometric patterns; replacement of metal dental fillings; laetrile or gerovital.

6.36 Pain management invasive procedures as defined by HPN’s protocols for chronic, intractable pain unless Prior Authorized by

HPN and provided by a Plan Provider who is a pain management Specialist. Any Prior Authorized pain management

procedures will be subject to the applicable facility and professional Copayments and/or Coinsurance amount as set forth in

Attachment A Benefit Schedule.

6.37 Acupuncture or hypnosis.

6.38 Treatment of an Illness or Injury caused by or arising out of a riot, declared or undeclared war or act of war, insurrection,

rebellion, armed invasion or aggression.

6.39 Treatment of an occupational Illness or Injury which is any Illness or Injury arising out of or in the course of employment for

pay or profit.

6.40 Travel and accommodations, whether or not recommended or prescribed by a Provider, other than as specifically covered in

this Plan.

6.41 Services provided at a Free Standing Facility or diagnostic Hospital-based Facility without Prior Authorization through the

HPN Managed Care Program. Services, which are self-directed to a Free Standing Facility or diagnostic Hospital-based

Facility. Services ordered by a Physician or other provider who is an employee or representative of a Free Standing Facility or

diagnostic Hospital-based Facility, when that Physician or other provider:

 Has not been involved in your medical care prior to ordering the service, or

 Is not involved in your medical care after the service is received.

This exclusion does not apply to mammography.

6.42 Care for conditions that federal, state or local law requires to be treated in a public facility for which a charge is not normally

made.

6.43 Any equipment or supplies that condition the air. Arch supports, support stockings, special shoe accessories or corrective shoes

unless they are an integral part of a lower-body brace. Heating pads, hot water bottles, wigs and their care and other primarily

nonmedical equipment. Incontinence supplies (diapers, pads, adult briefs) and bath aids (rails, shower chairs, bath benches).

6.44 Any service or supply in connection with routine foot care, including the removal of warts, corns, or calluses, the cutting and

trimming of toenails, or foot care for flat feet, fallen arches and chronic foot strain in the absence of severe systemic disease.

6.45 Special formulas, orally administered formulas, nutritional supplements, food supplements other than as specifically covered in

this Plan or special diets on an outpatient basis (except for the treatment of inherited metabolic disease).

6.46 Services, supplies or accommodations provided without cost to the Member or for which the Member is not legally required to

pay.

6.47 Milieu therapy, biofeedback treatment, behavior modification, sensitivity training, hypnosis, hydrotherapy, electrohypnosis,

electrosleep therapy, electronarcosis, narcosynthesis, rolffing, vocational rehabilitation and wilderness programs.

6.48 Experimental, Investigational, or Unproven treatment or devices as determined by HPN.

6.49 Sports medicine treatment plans intended to primarily improve athletic ability.

6.50 Radial keratotomy or any surgical procedure for the improvement of vision when vision can be made adequate through the use

of glasses or contact lenses.

6.51 Services requested or performed by a Provider who is a family member by birth or marriage. Examples include a spouse,

brother, sister, parent or child. This includes any service the Provider may perform on him/herself. Services performed by a

Provider with the same legal address as the Member.

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6.52 Ambulance services when a Member could be safely transported by other means. Air Ambulance services when a Member

could be safely transported by ground Ambulance or other means.

6.53 Late discharge billing and charges resulting from a canceled appointment or procedure.

6.54 Telemetry readings, EKG interpretations when billed separately from the EKG procedure.

6.55 Arterial blood gas interpretations when billed separately from the procedure.

6.56 Services of more than one (1) assistant surgeon at one (1) operative session, unless approved in advance by HPN or its Medical

Director. Service of an assistant surgeon when the Hospital provides or makes available qualified staff personnel (including

Physicians in training status) as surgical assistants. Services of an assistant surgeon provided solely to meet a Hospital’s

institutional requirements when the complexity of the surgery does not warrant an assistant surgeon.

6.57 Autologous blood donations.

6.58 Covered Services received in connection with a clinical trial or study which includes the following:

 Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or

medical industry;

 Healthcare services that are specifically excluded from coverage under this Plan regardless of whether such services are

provided under the clinical trial or study;

 Healthcare services that are customarily provided by the sponsors of the clinical trial or study free of charge to the Member in

the clinical trial or study;

 Extraneous expenses related to participation in the clinical trial or study including, but not limited to, travel, housing and

other expenses that a Member may incur;

 Any expenses incurred by a person who accompanies the 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; and

 Any cost for the management of research relating to the clinical trial or study.

6.59 If you are eligible for Medicare, any services covered by Medicare under Parts A and B are excluded to the extent actually paid

for by Medicare.

6.60 Services provided by non-participating vision care providers.

6.61 Charges for services by a vision Plan Provider to his or her Dependents.

6.62 Visual therapy.

6.63 Replacement of lost or stolen eyewear.

6.64 Two pairs of eyeglasses in lieu of bifocals.

6.65 Services or materials provided under Workers’ Compensation or Employer’s Liability laws.

6.66 Services provided or paid for by governmental agency or under any governmental program or law, except charges which the

Member is legally obligated to pay.

6.67 Services performed for cosmetic purposes or to correct congenital malformations.

6.68 Any dental services and supplies not provided for in the Agreement of Coverage, not Medically Necessary as defined by the

Agreement of Coverage or not required in accordance with the accepted standards of dental practice of the community

including:

 Services provided by non-participating dentists.

 Charges for services by a dental Plan Provider to his or her Dependents.

 Restorations using gold foil and any precious metal restoration when the tooth can be restored using other filling

materials.

 Bonding for cosmetic purposes.

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 Routine extractions for asymptomatic third (3

) molar teeth.

 Routine extraction of loose deciduous teeth.

6.69 Services received in connection with Gender Dysphoria, which includes the following

 Abdominoplasty;

 Blepharoplasty;

 Body contouring, such as lipoplasty;

 Breast enlargement, including augmentation mammoplasty and breast implants;

 Brow lift;

 Calf implants;

 Cheek, chin, and nose implants;

 Cryopreservation of fertilized embryos;

 Drugs for hair loss or growth;

 Face lift, forehead lift, or neck tightening;

 Facial bone remodeling for facial feminizations;

 Hair removal;

 Hair transplantation;

 Injection of fillers or neurotoxins;

 Lip augmentation;

 Lip reduction;

 Liposuction;

 Mastopexy;

 Pectoral implants for chest masculinization;

 Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics;

 Rhinoplasty;

 Skin resurfacing;

 Sperm preservation in advance of hormone treatment or gender surgery;

 Surgical or hormone treatment on Members under eighteen (18) years of age;

 Surgical treatment not Prior Authorized by HPN;

 Thyroid cartilage reduction; reduction thyroid chondroplasty; trachea shave (removal or reduction of the Adam’s

Apple);

 Transportation, meals, lodging or other similar expenses;

 Voice lessons and voice therapy; and

 Voice modification surgery.

6.70 Non-Medical 24-Hour Withdrawal Management.

6.71 Nutritional supplements, vitamins, herbal medicines, appetite suppressants, and over-the-counter drugs, except as specifically

covered herein. Drugs and medicines approved by the FDA for Experimental, Investigational or Unproven use except when

prescribed for the treatment of cancer or chronic fatigue syndrome under a clinical trial or study approved by the Plan.

6.72 Drugs and medicine approved by the FDA for Experimental, Investigational or Unproven use or any drug that has been

approved by the FDA for less than one (1) year.

6.73 Physician-assisted Suicide and any information, services or pharmaceuticals associated.

6.74 Healthcare services from a Non-Plan Provider for non-emergent, sub-acute inpatient or outpatient services at any of the

following non-Hospital facilities: Alternate Facility, Free Standing Facility, Residential Treatment Center, Inpatient

Rehabilitation Facility or Skilled Nursing Facility received outside of the Member’s state of residence. For the purpose of this

exclusion the "state of residence" is the state where the Member is a legal resident, plus any geographically bordering adjacent

state or, for a Member who is a student, the state where they attend school during the school year. This exclusion does not apply

in the case of an Emergency or if prior authorization has been obtained in advance.

6.75 Transitional Living

6.76 High intensity residential care, including American Society of Addiction Medicine (ASAM) Criteria, for Covered Persons with

substance-related and addictive disorders who are unable to participate in their care due to significant cognitive impairment.

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Pharmacy Specific Exclusions

6.77 Prescription Drug furnished by the local, state or federal government. Any Prescription Drug to the extent payment or benefits

are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or

benefits are received, except as otherwise provided by law.

6.78 Nutritional supplements, vitamins, herbal medicines, appetite suppressants, and over-the-counter drugs, except as specifically

covered by this Plan. Drugs and medicines approved by the FDA for Experimental, Investigational or Unproven use except

when prescribed for the treatment of cancer or chronic fatigue syndrome under a clinical trial or study approved by the Plan.

Any drug that has been approved by the FDA for less than one (1) year.

6.79 Prescription Drugs for any condition, Injury, Illness or Mental Illness arising out of, or in the course of, employment for which

benefits are available under any workers’ compensation law or other similar laws, whether or not a claim for such benefits is

made or payment or benefits are received.

6.80 Any product dispensed for the purpose of appetite suppression or weight loss.

6.81 Medications used for cosmetic purposes.

6.82 Prescription Drug Products when prescribed to treat infertility.

6.83 Any medication that is used for the treatment of erectile dysfunction or sexual dysfunction.

6.84 Hypodermic needles, syringes, or similar devices used for any purpose other than the administration of Specialty Covered

Drugs.

6.85 Except as otherwise specifically provided, Prescription Drugs related to medical services which are not covered under the HPN

AOC.

6.86 Drugs for which prescriptions are written by a licensed Provider for use by the Provider or by his or her immediate family

members.

6.87 Prescription Drugs, including Covered Drugs, dispensed by a Non-Plan Provider, except in the case of Emergency Services and

Urgently Needed Services.

6.88 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. Such determinations may be made up to six

times during a calendar year, and HPN may decide at any time to reinstate benefits for a Prescription Drug that was previously

excluded under this provision.

6.89 General vitamins, except the following which require a prescription order or refill: prenatal vitamins; vitamins with fluoride;

and single entity vitamins.

6.90 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.

6.91 Certain Prescription Drugs that are FDA approved as a package with a device or application, including smart package sensors

and/or embedded drug sensors. This exclusion does not apply to a device or application that assists you with the administration

of a Prescription Drug.

6.92 Any Prescription Drug for which the actual charge to the Member is less than the amount due under this Plan.

6.93 Any refill dispensed more than one (1) year from the date of the latest prescription order or as permitted by applicable law of

the jurisdiction in which the drug is dispensed.

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6.94 Prescription Drugs as a replacement for a previously dispensed Prescription Drug that was lost, stolen, broken or destroyed.

6.95 Coverage for Prescription Drugs for the amount dispensed (days’ supply, quantity limitation, dose, regimen, or frequency)

which is less than or exceeds the supply limit.

6.96 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. (Compounded drugs that contain at least one ingredient that requires a Prescription

Order or Refill are assigned to tier III or IV).

6.97 Prescriptions for Covered Drugs for which Prior Authorization is required but not obtained.

6.98 Experimental, Investigational or Unproven services and medications; medication used for experimental indications and/or

dosage regimens determined by the Plan to be Experimental, Investigational or Unproven except when prescribed for the

treatment of cancer or other life-threatening diseases or conditions, chronic fatigue syndrome, cardiovascular disease, surgical

musculoskeletal disorder of the spine, hip and knees, and other diseases or disorders which are not life threatening or study

approved by the Plan.

6.99 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.

6.100 Prescription Drugs dispensed outside the United States, except as required for emergency treatment.

6.101 Covered Drugs which are prescribed, dispensed or intended for use during an Inpatient admission.

6.102 Biosimilar Prescription Drugs.

6.103 Publicly available software applications and/or monitors that may be available with or without a Prescription Order or Refill.

6.104 Covered Drugs that are not FDA approved for a specific diagnosis.

6.105 Drugs and medicine approved by the FDA for Experimental, Investigational or Unproven use.

6.106 Drugs and medicine that have been approved by the FDA for less than one (1) year.

6.107 Drugs not approved by the FDA.

6.108 Unit dose packaging and repackaging of Prescription Drugs.

SECTION 7. Limitations

This section tells you when HPN's duty to provide or arrange for services is limited.

7.1 Liability

HPN will not be liable for any delay or failure to provide or arrange for Covered Services if the delay or failure is caused by the

following:

 Civil insurrection;

 Epidemic;

 Natural disaster;

 Riot;

 War;

 Or any other emergency beyond HPN’s control.

In the event of one of these types of emergencies, HPN and its Plan Providers will provide the Covered Services shown in this AOC to

the extent practical according to their best judgment.

7.2 Calendar Year and Lifetime Maximum Benefit Limitations

Please see the Attachment A Benefit Schedule for Calendar Year and/or lifetime maximums applicable to certain benefits.

Agreement of Coverage

22H_IN_AOC_RX

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7.3 Reimbursement

Reimbursement for Covered Services approved by HPN and provided by a Non-Plan Provider outside HPN’s Service Area shall be

limited to the average payment which HPN makes to Plan Providers in HPN’s Service Area.

SECTION 8. Coordination of Benefits (COB)

This section tells you how other health insurance you may have affects your coverage under this Plan. NOTE: This plan is always

secondary to a stand-alone dental plan for certain services pursuant to Nevada state regulations.

8.1 The Purpose of COB

Coordination of Benefits (COB) is intended to help contain the cost of providing healthcare coverage. When an individual person has

dual coverage through HPN and another healthcare plan, the COB guidelines outlined in this Section apply. The COB guidelines

explain how, in a dual healthcare coverage situation, benefits are coordinated or shared by each plan.

8.2 Benefits Subject to COB

All of the healthcare benefits provided under this AOC are subject to this Section. The Member agrees to permit HPN to coordinate

its obligations under this AOC with payments under any other Health Benefit Plan that covers the Member.

8.3 Definitions

Some words in this Section have a special meaning to meet the needs of this Section. These words and their meaning when used are:

(a) “Plan” will mean an entity providing healthcare benefits or services by any of the following methods:

1. Insurance or any other arrangement for coverage for individuals whether on an insured or uninsured basis, including the

following:

a. Hospital indemnity benefits with regard to the amount in excess of $30 per day.

b. Hospital reimbursement type plans which permit the insured person to elect indemnity benefits at the time of claim.

2. Service plan contracts, group practice, individual practice and other prepayment coverage.

3. Any coverage for students that is sponsored by, or provided through, school or other educational institutions, other than

accident coverage for grammar school or high school students that the parent pays the entire premium.

4. Any coverage under labor management trusteed plans, union welfare plans, employer organization plans, employee benefit

plans, or employee benefit organization plans.

5. Coverage under a governmental program, including Medicare and workers' compensation plans.

The term "Plan" will be construed separately with respect to each policy, contract or other arrangement for benefits or services

and separately with respect to that portion of any such policy, contract or other arrangement which reserves the right to take the

benefits or services of other Plans into consideration in determining its benefits and that portion which does not.

(b) “Allowable Expense” means the Eligible Medical Expense for Medically Necessary Covered Services. When a Plan provides

benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be an

Allowable Expense and a benefit paid.

(d) “Primary Plan” means a Plan that, in accordance with the rules regarding the order of benefits determination, provides benefits

or benefit payments without considering any other Plan.

(e) “Secondary Plan” means a Plan that in accordance with the rules regarding the order of benefit determination, may reduce its

benefits or benefit payments and/or recover from the Primary Plan benefit payments.

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8.4 When COB Applies

COB applies when a Member covered under this Plan is also entitled to receive payment for or provision of some or all of the same

Covered Services from another Plan.

8.5 Determination Rules

The rules establishing the order of benefit determination are:

(a) Non-Dependent or Dependent. A Plan that covers the person as a Subscriber is primary to a Plan that covers the person as a

Dependent.

(b) Dependent Child of Parents Not Separated or Divorced. Except as stated in 8.5(c) below, when this Plan and another Plan

cover the same child as a Dependent of different parents:

1. The Plan of the parent whose birthday falls earlier in the Calendar Year is primary to the Plan of the parent whose birthday

falls later in the year.

2. If both parents have the same birthday, the Plan that has covered a parent for a longer period of time is primary.

3. If the other Plan does not have the rule described in (1) immediately above, but instead has a rule based on the gender of the

parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of

benefits.

(c) Dependent Child of Separated or Divorced Parents. If two (2) or more Plans cover a person as a Dependent child of divorced

or separated parents, benefits for the child are determined in this order:

1. If there is a court decree that would establish financial responsibility for the medical, dental or other healthcare expenses with

respect to the child, the benefits of a Plan that covers the child as a Dependent of the parent with such financial responsibility

shall be determined before the benefits of any other Plan that covers the child as a Dependent child;

2. Second, the Plan of the parent with custody of the child;

3. Third, the Plan of the spouse (stepparent) of the parent with custody of the child;

4. Finally, the Plan of the parent not having custody of the child.

(d) Active/Inactive Subscriber. A Plan that covers a person as a Subscriber who is neither laid-off nor retired (or that Subscriber's

Dependents) is primary to a Plan that covers that person as a laid-off or retired Subscriber (or that Subscriber's Dependents). If

the other Plan does not have this rule, and if as a result, the Plans do not agree on the order of benefits, this rule (d) is ignored.

(e) Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the Plan that covered the

person for a longer period of time is primary to the Plan which covered that person for the shorter time period.

Two consecutive Plans shall be treated as one Plan if:

1. That person was eligible under the second Plan within 24 hours after the termination of the first Plan; and

2. There was a change in the amount or scope of a Plan's benefits or there was a change in the entity paying, providing or

administering Plan benefits; or

3. There was a change from one type of Plan to another (e.g., single employer to multiple employer Plan).

(f) If No COB Provision. If another Plan does not contain a provision coordinating its benefits with those of this Plan, the benefits

of such other Plan will be considered primary.

8.6 How COB Works

Plans use COB to decide which healthcare coverage programs should be the Primary Plan for the Covered Service. If the Primary

Plan payment is less than the charge for the Covered Service, then the Secondary Plan will apply its Allowable Expense to the unpaid

balance. Benefits payable under another Plan include the benefits that would have been payable if the Member had filed a claim for

them.

8.7 Right to Receive and Release Information

In order to decide if this COB Section (or any other Plan's COB Section) applies to a claim, HPN (without the consent of or notice to

any person) has the right to the following:

(a) Release to any person, insurance company or organization, the necessary claim information.

(b) Receive from any person, insurance company or organization, the necessary claim information.

(c) Require any person claiming benefits under this Plan to give HPN any information needed by HPN to coordinate those benefits.

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22H_IN_AOC_RX

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8.8 Facility of Payment

If another Plan makes a payment that should have been made by HPN, then HPN has the right to pay the other Plan any amount

necessary to satisfy HPN's obligation. Any amount paid shall be deemed to be benefits paid under this Plan, and to the extent of such

payments, HPN shall be fully discharged from liability under this Plan.

8.9 Right to Recover Payment

If the amount of benefit payment exceeds the amount needed to satisfy HPN's obligation under this section, HPN has the right to

recover the excess amount from one or more of the following:

(a) Any persons to or for whom such payments were made;

(b) Any insurance companies or service plans;

8.10 Failure to Cooperate

If a Member fails to cooperate with HPN’s administration of this section, the Member may be responsible for the expenses for the

services rendered and if legal action is taken, a court could make the Member responsible for any legal expense incurred by HPN to

enforce its rights under this section.

Member cooperation includes the completion of the necessary paperwork that would enable HPN to collect payment from the Primary

Plan for services. Any benefits paid to the Member in excess of actual expenses must be refunded to HPN.

SECTION 9. Premium Payments, Grace Period and Changes in Premium Rates

This section tells you when premium payments are due, what happens when payments are not received and when premium rates can

change.

9.1 Monthly Payments

The first day of any calendar month is the premium due date. On or before the premium due date, the Subscriber shall remit to HPN,

on behalf of the Subscriber and his covered Family Members the premium amount specified by HPN.

9.2 Grace Period

Only Members for whom premium payment is actually received by HPN shall be entitled to Covered Services hereunder and then

only for the period for which such payment is received. HPN shall not be liable for any healthcare services incurred by any Member

beyond the period for which the premium payments shall have been paid, and HPN shall be entitled to receive reimbursement from the

Subscriber for any claims paid by HPN for services provided after the date of termination.

9.3 Changes in Premium Payments

HPN reserves the right to establish a revised schedule of premium payments provided it gives the Subscriber thirty (30) day notice

prior to the Annual Open Enrollment as established by Federal guidelines.

9.4 Past Due Premiums

To the extent permitted by applicable State law, HPN may assign any past-due premium amounts owed for coverage in the twelve

(12) month period preceding the requested effective date of any new coverage when determining whether an individual or employer

has made an initial premium payment to effectuate new coverage.

9.4 Third Party Payment of Premiums

The following are the only acceptable third parties who may pay HPN premiums on the Member’s behalf:

 Ryan White HIV/AIDS program under Title XXVI of the Public Health Service Act;

 Indian tribes, tribal organizations, or urban Indian organizations;

 Employer;

 State and Federal government programs; or

 Family members.

If payment from the Member is received and premium is determined to be from an non-acceptable third party, the Member will be

informed that the payment will be returned and that the premium payment remains due by an acceptable party. If the premium

payment is not received from an acceptable party within the premium grace period the policy will be terminated for nonpayment of

premium.

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22H_IN_AOC_RX

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SECTION 10. General Provisions

10.1 Relationship of Parties

The relationship between HPN and Plan Providers is an independent contractor relationship. Plan Providers are not agents or

employees of HPN; nor is HPN, or any employee of HPN, an employee or agent of a Plan Provider. HPN is not liable for any claim

or demand on account of damages as a result of, or in any manner connected with, any Injury suffered by a Member while receiving

care from any Plan Provider or in any Plan Provider's facility. HPN is not bound by statements or promises made by its Plan

Providers.

10.2 Entire Agreement

This AOC, including the Attachment A Benefit Schedule and any other Attachments, Endorsements, Riders or Amendments to it, the

Member’s Enrollment Application Form, health statements, Member Identification Card, and all other applications received by HPN

constitutes the entire agreement between the Member and HPN and as of its Effective Date, replaces all other agreements between the

parties.

For the duration of time a Member’s coverage is continuously effective under HPN, regardless of the occurrence of any specific Plan

or product changes during such time, all benefits paid by HPN under any and all such Plans on behalf of such Member shall

accumulate towards any applicable lifetime or other maximum benefit amounts as stated in the Member’s most current Plan

Attachment A Benefit Schedule to the AOC.

This policy, including the Endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this

policy shall be valid until approved by an executive officer of the insurer and unless such approval is endorsed hereon or attached

hereto. No agent has authority to change this policy or to waive any of its provisions.

In the event HPN decides to discontinue offering and renewing health benefit plans delivered or issued for delivery in this state, HPN

will provide notice of its intention to all persons covered by the discontinued insurance at least ninety (90) days before the nonrenewal

of any health benefit plan by HPN.

10.3 Payment of Benefits

Payment of benefits by HPN shall be in cash or cash equivalents, or in a form of other consideration that HPN determines to be

adequate. Where benefits are payable directly to a Provider, such adequate consideration includes the forgiveness in whole or in part

of the amount the Provider owes to HPN, or to other Health Benefit Plans’ for which HPN makes payments where HPN has taken an

assignment of the other plans' recovery rights for value.

10.4 Contestability

Any and all statements made to HPN by any Subscriber or Dependent, will, in the absence of fraud, be considered representations and

not warranties. Also, no statement, unless it is contained in a written application for coverage, shall be used in defense to a claim

under this agreement.

10.5 Authority to Change the Form or Content of AOC

No agent or employee of HPN is authorized to change the agreement or waive any of its provisions. Such changes can be made only

through an amendment authorized and signed by an officer of HPN.

10.6 Identification Card

Cards issued by HPN to Members are for identification only. Possession of the HPN identification card does not give right to services

or other benefits under this Plan.

To be entitled to such services or benefits, the holder of the card must in fact be a Member and all applicable premiums must actually

have been paid. Any person not entitled to receive services or other benefits will be liable for the actual cost of such services or

benefits.

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10.7 Notice

Any notice under this Plan may be given by United States mail, first class, postage paid, addressed as follows:

Health Plan of Nevada, Inc.

P.O. Box 15645

Las Vegas, Nevada 89114 5645

Notice to a Member will be sent to the Member's last known address.

10.8 Interpretation of AOC

The laws of the jurisdiction of issue shall be applied to interpretation of this AOC. Where applicable, the interpretation of this AOC

shall be guided by the direct-service nature of HPN's operation as opposed to a fee-for-service indemnity basis.

10.9 Assignment

This Plan is not assignable without the written consent of HPN. The coverage and any benefits under this Plan are not assignable by

any Member without the written consent of HPN.

10.10 Modifications

This Plan is subject to amendment, modification and termination with sixty (60) days written notice to the Member. This Plan will

automatically be modified to conform with any State or Federal law requirements. HPN reserves the right to establish a revised

schedule of premium payments provided it gives the Subscriber thirty (30) day notice prior to the Annual Open Enrollment as

established by Federal guidelines.

By electing medical coverage with HPN or accepting benefits under this Plan, all Members legally capable of contracting, and the

legal representatives of all Members incapable of contracting, agree to all of the terms and provisions.

10.11 Clerical Error

Clerical error in keeping any record pertaining to the coverage will not invalidate coverage in force or continue coverage terminated.

10.12 Policies and Procedures

HPN may adopt reasonable policies, procedures, rules and interpretations to promote the orderly and efficient administration of this

Plan with which Members shall comply. These policies and procedures are maintained by HPN at its offices. Such policies and

procedures may have bearing on whether a medical service and/or supply is covered.

10.13 Overpayments

If HPN pays benefits for expenses incurred on account of an enrolled Member, that Member or any other person or organization that

was paid, must make a refund to HPN if any of the following apply:

 If the refund is due from the Member and the Member does not promptly refund the full amount, HPN may recover the

overpayment by reallocating the overpaid amount to pay, in whole or in part, future benefits for the Member that are payable

under the policy. If the refund is due from a person or organization other than the Member, HPN may recover the overpayment by

reallocating the overpaid amount to pay, in whole or in part:

o future benefits that are payable in connection with services provided to other Members under the policy; or

o future benefits that are payable in connection with services provided to persons under other plans for which we make

payments, pursuant to a transaction in which HPNs overpayment recovery rights are assigned to such other Health

Benefit Plan’s in exchange for such Plans' remittance of the amount of the reallocated payment.

10.14 Cost Containment Features

This Plan contains at least the following cost containment provisions:

 Preventive healthcare benefits.

 HPN’s Managed Care Program.

 Benefit limitations on certain services.

 Member Copayments.

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10.15 Release of Records

Each Member authorizes the Physician, Hospital, Skilled Nursing Facility or any other Provider of healthcare to permit the

examination and copying of the Member's medical records, as requested by HPN.

Information from medical records and information received from Physicians or Hospitals incident to the Physician/Patient relationship

or Hospital/Patient relationship shall be kept confidential and, except for use in connection with government requirements established

by law or the administration of this Plan, records may not be disclosed to any unrelated third party without the Member’s consent.

10.16 Reimbursement for Claims

Non-Plan Providers may require immediate payment for their services and supplies. When seeking reimbursement from HPN for

expenses incurred in connection with services received from Non-Plan Providers, the Member must complete a Non-Plan Provider

Claim Form and submit it to the HPN Claims Department with copies of all of the medical records, bills and/or receipts from the

Provider. Non-Plan Provider Claim Forms can be obtained by calling the Member Services Department at 888-293-6831.

If the Member receives a bill for Covered Services from a Non-Plan Provider, the Member may request that HPN pay the Provider

directly by sending the bill, with copies of all medical records and a completed Non-Plan Provider Claim Form to the HPN Claims

Department.

HPN shall approve or deny a claim within thirty (30) days after receipt of the claim. If the claim is approved, the claim shall be paid

within thirty (30) days from the date it was approved. If the approved claim is not paid within that thirty (30) day period, HPN shall

pay interest on the claim at the rate set forth by applicable Nevada law. The interest will be calculated from thirty (30) days after the

date on which the claim is approved until the date upon which the claim is paid.

HPN may request additional information to determine whether to approve or deny the claim. HPN shall notify the Provider of its

request for additional information within twenty (20) days after receipt of the claim. HPN will notify the Provider of the healthcare

services of all the specific reasons for the delay in approving or denying the claim. HPN shall approve or deny the claim within thirty

(30) days after receiving the additional information. If the claim is approved, HPN shall pay the claim within thirty (30) days after it

receives the additional information. If the approved claim is not paid within that time period, HPN shall pay interest on the claim in

the manner set forth above.

If HPN denies the claim, notice to the Member will include the reasons for the rejection and the Member’s right to file a written

complaint as set forth in the Appeals Procedures section herein.

10.17 Timely Filing Requirements

All claims must be submitted to HPN within sixty (60) days from the date expenses were incurred, unless it shall be shown not to have

been reasonably possible to give notice within the time limit, and that notice was furnished as soon as was reasonably possible. If

Member authorizes payment directly to the Provider, a check will be mailed to that Provider. A check will be mailed to the Member

directly if payment directly to the Provider is not authorized. Member will receive an explanation of how the payment was

determined.

No payments shall be made under this Plan with respect to any claim, including additions or corrections to a claim which has already

been submitted, that is not received by HPN within twelve (12) months after the date Covered Services were provided. In no event

will HPN pay more than HPN’s Eligible Medical Expenses, or the Recognized Amount when applicable, for such services.

10.18 Gender References

Whenever a masculine pronoun is used in this AOC, it also includes the feminine pronoun.

10.19 Legal Proceedings

No action of law or equity shall be brought to recover on the Plan prior to the expiration of sixty (60) days after proof of claim has

been filed according to the requirements of the Plan. No such action shall be brought at any time unless brought within the time limit

allowed by the laws of the jurisdiction of issue.

If the laws of the jurisdiction of issue do not designate the maximum length of time in which such action may be brought, no action

may be brought after the expiration of three (3) years from the time proof of loss is required by the Plan.

10.20 Availability of Providers

HPN does not guarantee the continued availability of any Plan Provider.

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10.21 Physician Incentive Plan Disclosure

You are entitled to ask if HPN has special financial arrangements with their contracted Physicians that may affect Referral services,

such as lab tests and hospitalizations that you might need. To receive information regarding contracted Physician payment

arrangements, please call the Member Services Department at 888-293-6831. This information will be sent to you within thirty (30)

days of the date that you make your request.

HPN will provide information on the financial arrangements that they have with their contracted Physicians to any requesting

Member. The following information is available upon request, to current, previous and potential Plan Members:

 Whether HPN’s Managed Care Organization contracts or subcontracts include Physician incentive plans that affect the use of

Referral services.

 Information on the type of arrangements used.

 Whether special insurance called stop-loss protection is required for Physicians or Physician’s groups.

10.22 Authorized Representative

A Member may elect to designate an “Authorized Representative” to act on their behalf to pursue a Claim for Benefits or the appeal of

an Adverse Benefit Determination. The term Member also includes the Member’s Authorized Representative, where applicable and

appropriate. To designate an Authorized Representative, a written notice, signed and dated by the Member, is required. The notice

must include the full name of the Authorized Representative and must indicate specifically for which Claim for Benefits or appeal the

authorization is valid. The notice should be sent to:

Health Plan of Nevada, Inc.

Attn: Customer Response and Resolution Dept.

P.O. Box 15645

Las Vegas, NV 89114-5645

Any correspondence from HPN regarding the specified Claim for Benefits or appeal will be provided to both the Member and his

Authorized Representative.

In case of an Urgent Care Claim, a healthcare professional with knowledge of the Member’s medical condition shall be permitted to

act as an Authorized Representative of the Member without designation by the Member.

10.23 Failure to Obtain Prior Authorization

The Member’s Physician must initiate all requests for Prior Authorization. If a Physician or Member fails to follow the Plan’s

procedures for filing a request for Prior Authorization (Pre-Service Claim), the Member shall be notified of the failure and the proper

procedures to be followed in order to obtain Prior Authorization. The Member’s request for Prior Authorization must be received by

an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must

specifically name the Member, the specific medical condition or symptom and the specific treatment, service or product for which

approval is requested. The Member notification of correct Prior Authorization procedures from the Plan shall be provided as soon as

possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of

the Member’s original request. Notification by HPN may be oral unless specifically requested in writing by the Member.

10.24 Timing of Notification of Benefit Determination

Concurrent Care Decision: If HPN has approved an ongoing course of treatment to be provided over a period of time or number of

treatments and reduces or terminates coverage of such course of treatment (other than by Plan amendment or termination) before the

end of such period of time or number of treatments, HPN will notify the Member at a time sufficiently in advance of the reduction or

termination to allow the Member to appeal and obtain a determination before the benefit is reduced or terminated. Subject to the

paragraph below, such request may be treated as a new Claim for Benefits and decided within the timeframes applicable to either a

Pre-Service Claim or a Post-Service Claim as appropriate. Provided, however, any appeal of such a determination must be made

within a reasonable time and may not be afforded the full 180 day period as described in the Appeals Procedures section herein.

Any request by a Member to extend the course of treatment beyond the period of time or number of treatments for an Urgent Care

Claim shall be decided as soon as possible. HPN shall notify the Member within twenty-four (24) hours after receipt of the Claim for

Benefits by the Plan, provided that the request is received at least twenty-four (24) hours prior to the expiration of the authorized

period of time or number of treatments. If the request is not made at least twenty-four (24) hours prior to the expiration of the

authorized period of time or number of treatments, the request will be treated as an Urgent Care Claim.

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10.25 Notification of an Adverse Benefit Determination

If you receive an Adverse Benefit Determination, you will be informed in writing of the following:

 The specific reason or reasons for upholding the Adverse Benefit Determination;

 Reference to the specific Plan provisions on which the determination is based;

 A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed,

and an explanation of why such material or information is necessary;

 A description of the review procedures and the time limits applicable to such procedures;

 For Member’s whose coverage is subject to ERISA, a statement of the Member’s right to bring a civil action under ERISA

Section 502(a) following an appeal of an Adverse Benefit Determination, if applicable;

 A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is

available free of charge upon the Member’s request; and

 If the Adverse Benefit Determination is based on Medical Necessity or Experimental, Investigational or Unproven treatment or

similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be

provided free of charge.

10.26 Prior Healthcare Coverage

If the Member has prior coverage that, as required by state law, extends benefits for a particular condition or a disability, HPN will not

pay benefits for health care services for that condition or disability until the prior coverage ends. HPN will pay benefits as of the day

coverage begins under the Plan for all other Covered Services that are not related to the condition or disability for which the Member

has other coverage.

SECTION 11. Pharmacy Provisions

11.1 Obtaining Covered Drugs

Benefits for Covered Drugs are payable subject to the following conditions:

 A Designated Plan Pharmacy must dispense the Covered Drug, except as otherwise specifically provided herein.

 A Generic Covered Drug will be dispensed when available, subject to the prescribing Provider’s “Dispense as written”

requirements.

 Benefits for Specialty Covered Drugs as defined herein are payable subject to the applicable tier Copayment and/or Coinsurance

for up to a thirty (30) day supply. If you require certain Covered Drugs, including, but not limited to, Specialty Drugs, HPN may

direct you to a Designated Plan Pharmacy with whom HPN has an arrangement to provide those Covered Drugs. If you choose

not to use the Designated Plan Pharmacy and instead have the Specialty Covered Drugs dispensed by a non-Designated Plan

Retail Pharmacy, you will be responsible for paying two times the amount of the Specialty Covered Drug Tier Copayment and/or

Coinsurance as stated in the applicable plan Attachment A, Schedule of Benefits.

 When a Prescription Drug is packaged or designed to deliver in a manner that provides more than a consecutive thirty (30) day

supply, the Cost-share that applies will reflect the number of days dispensed.

11.2 Designated Plan Pharmacy Benefit Payments

Benefits for Covered Drugs obtained at a Designated Plan Pharmacy are payable according to the applicable benefit tiers described

below, subject to the Member obtaining any required Prior Authorization or meeting any applicable Step Therapy requirement.

 Tier I – is the low Cost-share option for Covered Drugs.

 Tier II – is the midrange Cost-share option for Covered Drugs.

 Tier III – is the high Cost-share option for Covered Drugs.

 Tier IV – is the highest Cost-share option for Covered Drugs.

 Mandatory Generic benefit provision applies when:

 a Brand Name Covered Drug is dispensed and a Generic Covered Drug equivalent is available. After satisfying any

applicable CYD, the Member will pay the applicable tier Copayment and/or Coinsurance plus the difference between the

Eligible Medical Expenses, or the Recognized Amount when applicable, of the Generic Covered Drug and of the Brand

Name Covered Drug to the Designated Plan Pharmacy for each Therapeutic Supply. The difference in the amount between

such Brand Name and Generic Covered Drug paid by the Member does not accumulate to any otherwise applicable plan

Calendar Year Prescription Drug Deductible, overall plan CYD or annual Out of Pocket Maximum.

11.3 Emergency or Urgently Needed Services Prescription Drugs

Dispensed by a Plan Pharmacy. When a prescription is written by a Non-Plan Provider in connection with Emergency Services or

Urgently Needed Services as defined in the HPN AOC, the Member will pay to the Plan Pharmacy at the time the Covered Drug is

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dispensed, the Copayment and/or Coinsurance amount subject to the applicable tier benefit.

Dispensed by a Non-Plan Pharmacy. When a prescription is written by a Non-Plan Provider in connection with Emergency

Services or Urgently Needed Services as defined in the HPN AOC, the Member will pay to the Non-Plan Pharmacy at the time the

Covered Drug is dispensed, the full cost of the Covered Drug subject to the Non-Plan Pharmacy Benefits Payment subsection.

11.4 Non-Plan Pharmacy Benefit Payments

In order for claims for Covered Drugs obtained at a Non-Plan Pharmacy to be eligible for benefit payment, the Member must complete

and submit a Pharmacy Reimbursement Claim Form with the prescription label and register receipt to HPN or its designee.

Benefit payments are subject to the limitations and exclusions set forth in the HPN AOC as follows:

1. When any Covered Drug is dispensed, the benefit payment will be subject to HPN’s EME, or the Recognized Amount when

applicable, and any applicable tier Copayment and/or Coinsurance. The Member is responsible for any amounts exceeding

HPN’s benefit payment.

2. The Mandatory Generic benefit provision applies when any Brand Name Covered Drug is dispensed and a Generic Covered Drug

equivalent is available. The benefit payment is subject to HPN’s EME, or the Recognized Amount when applicable, of the

Generic Covered Drug less the applicable tier copayment. The Member is responsible for any amounts exceeding HPN’s benefit

payment.

3. No benefits are payable if HPN’s EME, or the Recognized Amount when applicable, of the Covered Drug is less than the

applicable Copayment and/or Coinsurance.

11.5 90 Day Retail Plan Network

(1)

and Mail Order Plan Pharmacy Benefit Payments

Benefits for Covered Drugs are available when dispensed by an HPN Retail

(1)

and Mail Order Plan Pharmacy subject to the applicable

tier Copayment. Information on how to obtain Mail Order Drugs is provided in the Mail Order Brochure provided after enrollment

with HPN.

(1)

Applies to select retail pharmacies, please consult your Provider directory.

11.6 Limitations

 Prior Authorization or Step Therapy may be required for certain Covered Drugs.

 Benefits are available for refills of Covered Drugs, including prescription eye drops and opioids, only when dispensed as ordered

by a duly licensed health care provider. Refills are provided once a given amount of the Covered Drug is used through the course

of therapy; amounts vary by the type of Covered Drug. Refill dates of Covered Drugs can be aligned so that drugs that are

refilled at the same frequency can be refilled concurrently.

 A pharmacy may refuse to fill or refill a prescription order when, in the professional judgment of the pharmacist, the prescription

should not be filled.

 Benefits are not payable if the Member is directed to a Designated Plan Pharmacy and chooses not to obtain the Covered Drug

from that Designated Plan Pharmacy.

 If HPN determines that the Member may be using Prescription Drugs in a harmful or abusive manner, or with harmful frequency,

the Member’s selection of Plan Pharmacies may be limited. If this happens, HPN may require the Member to select a single Plan

Pharmacy that will provide and coordinate all future pharmacy services. Benefit coverage will be paid only if the Member uses

the assigned single Plan Pharmacy. If a selection is not made by the Member within thirty-one (31) days of the date of

notification, then HPN will select a single Plan Pharmacy for the Member.

 Certain Specialty Prescription Drugs may be dispensed by the Designated Pharmacy in fifteen (15) day supplies up to ninety (90)

days and at a pro-rated Copayment or Coinsurance. The Member will receive a fifteen (15) day supply of the Specialty

Prescription Drug Product to determine if the Member will tolerate the Specialty Prescription Drug Product prior to purchasing a

full supply. The Designated Pharmacy will contact the Member each time prior to dispensing the fifteen (15) day supply to

confirm if the Member is tolerating the Specialty Prescription Drug Product. The list of these certain Specialty Prescription

Drugs is available through review of the HPN Prescription Drug List (PDL).

 If a Prescription Drug is excluded from coverage, the Member or representative may request an exception to gain access to the

excluded Prescription Drug. Exceptions do not apply to drugs that are considered benefit exclusions, such as drugs for sexual

dysfunction, cosmetic products and infertility.

To make a request, contact HPN in writing or call the toll-free number on your ID card. Please note, if the request for an

exception is approved by HPN, the Member may incur the cost of the excepted Prescription Drug at the highest tier. If the request

requires immediate action and a delay could significantly increase a health risk or the ability regain maximum function, call HPN

as soon as possible. HPN will provide a written or electronic determination within twenty-four (24) hours. If the Member is not

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satisfied with HPN determination of the exclusion exception, they may request an External Review. Please refer to the Appeals

Procedure section herein for further information.

 HPN may have certain programs in which the Member may receive an enhanced or reduced benefit based on their actions such as

adherence/compliance to medication or treatment regimens, and/or taking part in health management programs. Questions about

these programs can be directed to the Member Services telephone number on your ID card.

 HIV preventative drugs, subject to reasonable management techniques as determined by Nevada state law, when prescribed by a

participating Pharmacist.

 Coverage for self-administered hormonal contraceptives, provided without a prescription, when a Pharmacist complies with the

providing requirements protocols of the State Board of Pharmacy.

11.7 Coverage Policies and Guidelines

HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on HPN’s behalf. The PDL

Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a

number of factors including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to,

evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits

or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s

acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug.

Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be

listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was

prescribed by a Specialist Physician.

When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors

regarding covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual covered

person is a determination that is made by the covered person and the prescribing Physician.

NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times

specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug.

Questions about HPN’s PDL should be directed to the Member Services Department at 888-293-6831 or the PDL and the Pharmacy

Reimbursement Claim Form is available is available at http://healthplanofnevada.com/~/media/Files/HPN/pdf/Forms/OptumRx-

Reimbursement.ashx?la=en.

Coupons

HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Member’s annual

CYD and/or Out of Pocket Maximum or to reduce the Member’s Copayments and/or Coinsurance. Costs defrayed for the Member as

a result of pharmaceutical coupons are not Eligible Medical Expenses. Questions regarding which coupons or offers are available can

be addressed at healthplanofnevada.com.

At various times, HPN may send mailings or provide other communications that include a variety of messages, including information

about prescription and non-prescription drugs. These communications may include offers that enable the Member to purchase the

described product at a discount. In some instances, non-HPN entities may support and/or provide content for these communications

and offers. Only the Member and the Provider can determine whether a change in prescription and/or non-prescription drug regimen is

appropriate for the Member’s medical condition.

Variable Copayment Program: Certain Specialty Prescription Drugs are eligible for coupons or offers from pharmaceutical

manufacturers or affiliates that may reduce the cost for the Member’s Prescription Drug and HPN may help the Member determine

whether the Specialty Prescription Drug is eligible for this reduction. If the Member redeems a coupon from a pharmaceutical

manufacturer or affiliate, the Copayment and/or Coinsurance may vary. Please contact the telephone number on your ID card for an

available list of Specialty Prescription Drugs. If the Member chooses not to participate, they will pay the Copayment or Coinsurance

as described in the Attachment A Benefit Schedule.

The amount of the coupon will not count toward any applicable Calendar Year Deductible or Out of Pocket Maximums.

Rebates and Other Payments

HPN may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that a Member purchased

prior to meeting any applicable deductible. As determined by HPN, a portion of any rebates may be passed on to the Member and may

be taken into account in determining any applicable Copayment and/or Cost-share.

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HPN, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the

Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants

and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient

Prescription Drug benefit and, therefore, such amounts do not pass on to the Member.

SECTION 12. Appeals Procedures

The HPN Appeals Procedures are available to you in the event you are dissatisfied with some aspect of the Plan administration or you

wish to appeal an Adverse Benefit Determination. This procedure does not apply to any problem of misunderstanding or

misinformation that can be promptly resolved by the Plan supplying the Member with the appropriate information.

If a Member’s Plan is governed by ERISA, the Member must exhaust the mandatory level of mandatory appeal before bringing a

claim in court for a Claim of Benefits.

Concerns about medical services are best handled at the medical service site level before being brought to HPN. If a Member contacts

HPN regarding an issue related to the medical service site and has not attempted to work with the site staff, the Member may be

directed to that site to try to solve the problem there, if the issue is not a Claim for Benefits.

Please see the Glossary Terms Section herein for a description of the terms used in this section.

The following Appeals Procedures will be followed if the medical service site matter cannot be resolved at the site or if the concern

involves the Adverse Benefit Determination of a Claim for Benefits. All Appeals will be adjudicated in a manner designed to ensure

independence and impartiality on the part of the persons making the decision.

Formal Appeal: An appeal of an Adverse Benefit Determination filed either orally or in writing which HPN’s Customer Response

and Resolution Department investigates. If a Formal Appeal is resolved to the satisfaction of the Member, the appeal is closed. The

Formal Appeal is mandatory if the Member is not satisfied with the initial determination and the Member wishes to appeal such

determination.

Member Services Representative: An employee of HPN that is assigned to assist the Member or the Member’s Authorized

Representative in appealing an Adverse Benefit Determination.

12.1 Formal Appeal

A Formal Appeal must be submitted orally or in writing to HPN’s Customer Response and Resolution Department within 180 days of

an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse

Benefit Determination to which they relate.

A Formal Appeal shall contain at least the following information:

 The Member’s name (or name of Member and Member’s Authorized Representative), address, and telephone number;

 The Member’s HPN membership number ; and

 A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Member feels that the Adverse Benefit

Determination was wrong.

Additionally, the Member may submit any supporting medical records, Physician’s letters, or other information that explains why

HPN should approve the Claim for Benefits. The Member can request the assistance of a Member Services Representative at any time

during this process.

The Formal Appeals should be sent or faxed to the following:

Health Plan of Nevada, Inc.

Attn: Customer Response and Resolution Department

PO Box 14865

Las Vegas, NV 89114

Fax: 1-702-266-8813

HPN will investigate the appeal. When the investigation is complete, the Member will be informed, in writing, of the resolution within

thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by HPN for up to fifteen

(15) days, provided that:

 the extension is necessary due to matters beyond the control of HPN and

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 HPN notifies the Member, prior to the expiration of the initial thirty (30) day period, of the circumstances requiring the

extension and the date by which HPN expects to render a decision.

If the extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the notice of

extension shall specifically describe the required information and the Member shall be afforded at least forty-five (45) days from

receipt of the notice to provide the information.

If the Formal Appeal results in an Adverse Benefit Determination, the Member will be informed in writing of the following:

 The specific reason or reasons for upholding the Adverse Benefit Determination;

 Reference to the specific Plan provisions on which the determination is based;

 A statement that the Member is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all

documents, records, and other information relevant to the Member’s Claim for Benefits;

 A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is

available free of charge upon the Member’s request; and

 If the Adverse Benefit Determination is based on Medical Necessity or Experimental, Investigational or Unproven treatment or

similar exclusion or limit, either

o an explanation of the scientific or clinical judgment or

o a statement that such explanation will be provided free of charge as well as information regarding the Member’s right to

request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA).

Limited extensions may be required if additional information is required in order for HPN to reach a resolution.

If HPN is unable to resolve the Member’s appeal as additional information is required, HPN will contact the Member to obtain their

permission to withdraw the appeal. The Member will receive written notification that the appeal has been withdrawn and advised of

the ninety (90) day timeframe in which to reopen their appeal.

12.2 Expedited Appeal

The Member can ask (either orally or in writing) for an Expedited Appeal of an Adverse Benefit Determination for a Pre-Service

Claim that involves an Urgent Care Claim if the Member or his Physician believe that the health of the Member could be seriously

harmed by waiting for a routine appeal decision. Expedited Appeals are not available for appeals regarding denied claims for benefit

payment (Post-Service Claim) or for Pre-Service Claims that are not Urgent Care Claims. Expedited Appeals must be decided no later

than seventy-two (72) hours after receipt of the appeal, provided all necessary information has been submitted to HPN. If the initial

notification was oral, HPN shall provide a written or electronic explanation to the Member within seventy-two (72) hours after the

expedited appeal being filed.

If insufficient information is received, HPN shall notify the Member as soon as possible, but no later than twenty-four (24) hours after

receipt of the claim of the specific information necessary to complete the claim. The Member will be afforded a reasonable amount of

time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specified information. HPN shall

notify the Member of the benefit determination as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:

 HPN’s receipt of the specified information, or

 The end of the period afforded the Member to provide the specified information.

If the Member’s Physician

 requests an Expedited Appeal, or

 supports a Member’s request for an Expedited Appeal, and indicates that waiting for a routine appeal could seriously harm

the health of the Member or subject the Member to unmanageable severe pain that cannot be adequately managed without

care or treatment that is the subject of the Claim for Benefits,

HPN will automatically grant an Expedited Appeal.

If a request for an Expedited Appeal is submitted without support of the Member’s Physician, HPN shall decide whether the

Member’s health requires an Expedited Appeal. If an Expedited Appeal is not granted, HPN will provide a decision within thirty (30)

days, subject to the routine appeals process for Pre-Service Claims.

12.3 External Review

HPN offers to the Member or the Member’s Authorized Representative the right to an External Review of an adverse determination.

For the purposes of this section, a Member’s Authorized Representative is a person:

 to whom a Member has given express written consent to represent the Member in an External Review of an adverse

determination;

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 or a person authorized by law to provide substituted consent for a Member;

 or a family member of a Member or the Member’s treating provider only when the Member is unable to provide consent.

Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity,

appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN will

provide the Member notice of such an adverse determination which will include the following statement:

HPN has denied your request for the provision or payment of a requested healthcare service or course of treatment. You

may have the right to have our decision reviewed by health care professionals who have no association with us if our

decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or

effectiveness of the health care service or treatment you requested, by submitting a request for External Review to the Office

for Consumer Health Assistance.

Additionally, as per applicable law and regulations, the notice will provide the Member the information outlined herein as well as the

following:

 The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state

in which the Member resides.

 The right to receive correspondence in a culturally and linguistically appropriate manner.

The notice to the Member or the Member’s Authorized Representative will also include

 a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize

HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are

pertinent to the External Review,

 and any other forms as required by Nevada law or regulation.

The Member or the Member’s Authorized Representative may submit a request directly to OCHA for an External Review of an

adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member or the Member’s

Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of

Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include

the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any

associated medical records are confidential.

Address

Office for Consumer Health Assistance

3320 W. Sahara Ave., Suite 100

Las Vegas NV 89102

Telephone Number(s)

(702) 486-3587

(888) 333-1597

Fax: (702) 486-3586

Website

www.CHA@govcha.nv.gov

The determination of an IRO concerning an External Review in favor of the Member of an adverse determination is final, conclusive

and binding. Upon receipt of the notice of a decision by the IRO reversing an adverse determination, HPN shall immediately approve

coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination. The cost

of conducting an External Review of an adverse determination will be paid by HPN.

12.4 Standard External Review

The Member may submit a request for an External Review of an adverse determination under this section only after

 the Member has exhausted the internal HPN Appeals Procedures provided under this Plan or

 if HPN fails to issue a written decision to the Member within thirty (30) days after the date the appeal was filed, and the

Member or Member’s Authorized Representative did not request or agree to a delay or,

 if HPN agrees to permit the Member to submit the adverse determination to OCHA without requiring the Member to exhaust

all internal HPN appeals procedures.

In such event, the Member shall be considered to have exhausted the internal HPN appeals process.

Within five (5) days after OCHA receives a request for External Review, OCHA shall notify the Member, the Member’s Authorized

Representative and HPN that such request has been received and filed. As soon as practical, OCHA shall assign an IRO to review the

case.

Within five (5) days after receiving notification specifying the assigned IRO from OCHA, HPN shall provide to the selected IRO all

documents and materials relating to the adverse determination, including, without limitation:

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 Any medical records of the Member relating to the adverse determination;

 A copy of the provisions of this Plan upon which the adverse determination was based;

 Any documents used and the reason(s) given by HPN’s Managed Care Program for the adverse determination; and

 If applicable, a list that specifies each Provider who provided healthcare to the Member and the corresponding medical records

from the Provider relating to the adverse determination.

Within five (5) days after the IRO receives the required documentation from HPN, they shall notify the Member or the Member’s

Authorized Representative, if any additional information is required to conduct the review. If additional information is required, it

must be provided to the IRO within five (5) days after receiving the request. The IRO will forward a copy of the additional

information to HPN within one (1) business day after receipt.

The IRO shall approve, modify, or reverse the adverse determination within fifteen (15) days after it receives the information required

to make such a determination. The IRO shall submit a copy of its determination, including the basis thereof, to the:

 Member;

 Member’s Physician;

 Member’s Authorized Representative, if any; and

 HPN.

12.5 Expedited External Review

A request for an Expedited External Review may be submitted to OCHA after it receives proof from the Member’s Provider that the

adverse determination concerns:

 An inpatient admission;

 availability of inpatient care;

 continued stay or health care service for Emergency Services while still admitted to an inpatient facility; or

 failure to proceed in an expedited manner may jeopardize the life or health of the Member.

The OCHA shall approve or deny this request for Expedited External Review within seventy-two (72) hours after receipt of the above

required proof. If OCHA approves the request, it shall assign the request to an IRO no later than one (1) business day after approving

the request. HPN will supply all relevant medical documents and information used to establish the adverse determination to the IRO

within twenty-four (24) hours after receiving notice from the OCHA.

The IRO shall complete its Expedited External Review within forty-eight (48) hours after initially being assigned the case unless the

Member or the Member’s Authorized Representative and HPN agree to a longer time period.

The IRO shall notify the following parties no later than twenty-four (24) hours after completing its Expedited External Review:

 Member;

 Member’s Physician;

 Member’s Authorized Representative, if any; and

 HPN.

The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

12.6 Request for an External Review Due to Denial of Experimental, Investigational or Unproven Healthcare Service or

Treatment.

A Standard or Expedited External Review of an adverse determination due to a requested or recommended healthcare service or

treatment being deemed Experimental, Investigational or Unproven, is available in limited circumstances as outlined in the following

sections.

12.7 Standard External Review

The Member or Member’s Authorized Representative may within four (4) months after receiving notice of an adverse determination

subject to this section, submit a request to the OCHA for an External Review.

OCHA will notify HPN and/or any other interested parties within one (1) business day after the receipt of the request for External

Review. Within five (5) business days after HPN receives such notice and, subject to applicable Nevada law and regulation and

pursuant to this section, HPN will make a preliminary determination of whether the case is complete and eligible for External Review

according to Nevada law and regulations.

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Within one (1) business day of making such a determination, HPN will notify, in writing, the Member or the Member’s Authorized

Representative and OCHA, accordingly. If HPN determines that the case is incomplete and/or ineligible, HPN will notify the Member

in writing of such determination. Such notice shall include the required additional information or materials needed to make the

request complete and, if applicable, state the reasons for ineligibility and also state that such determination may be appealed to OCHA.

Upon appeal, OCHA may overturn HPN’s determination that a request for External Review of an adverse determination is ineligible,

and submit the request to External Review, subject to all of the terms and provisions of this Plan and applicable Nevada law and

regulation.

Within one (1) business day after receiving the confirmation of eligibility for External Review from HPN, OCHA will assign the IRO

accordingly and notify, in writing, the Member or the Member’s Authorized Representative and HPN that the request is complete and

eligible for External Review and provide the name of the assigned IRO. HPN, within five (5) days after receipt of such notice from

the OCHA, will supply all relevant medical documents and information used to establish the adverse determination to the assigned

IRO who will select and assign one or more clinical reviewers to the External Review.

The IRO shall approve, modify, or reverse the adverse determination pursuant to this section within twenty (20) days after it receives

the information required to make such a determination.

The IRO shall submit a copy of its determination, including the basis thereof, to the:

 Member;

 Member’s Physician;

 Member’s Authorized Representative, if any; and

 HPN.

12.8 Expedited External Review

The Member or the Member’s Authorized Representative may request, in writing, an internal Expedited appeal by HPN and an

Expedited External Review from OCHA simultaneously

 if the adverse determination of the requested or recommended service or treatment is determined by HPN to be Experimental,

Investigational or Unproven, and,

 if the treating Provider certifies, in writing, that such service or treatment would be less effective if not promptly initiated.

An oral request for an Expedited External Review may be submitted directly to the OCHA upon the written submission of proof from

the Member’s Provider to OCHA that such service or treatment would be significantly less effective if not promptly initiated. Upon

receipt of such request and proof, the OCHA shall immediately notify HPN accordingly.

HPN will immediately determine if the request meets the requirements for Expedited External Review pursuant to this section and

notify the Member or the Member’s Authorized Representative and the OCHA of the determination. If HPN determines the request to

be ineligible, the Member will be notified that the request may be appealed to OCHA.

If OCHA approves the request for Expedited External Review, it shall immediately assign the request to an IRO and notify HPN. The

IRO has one (1) business day to select one or more clinical reviewers. HPN must submit the documentation used to support the

adverse determination to the IRO within five (5) business days. If HPN fails to provide the information within the specified time, the

IRO may terminate the External Review and reverse the adverse determination.

The Member or Member’s Authorized Representative may, within five (5) business days after receiving notice of the assigned IRO,

submit any additional information in writing to the IRO. Any information submitted by the Member or the Member’s Authorized

Representative after five (5) business days to the IRO may be considered as well. Any information received by the Member or the

Member’s Authorized Representative must be submitted to HPN by the IRO within one (1) business day.

The clinical reviewers have no more than five (5) days to provide an opinion to the IRO. The IRO has forty-eight (48) hours to review

the opinion of the clinical reviewers and make a determination.

The IRO shall notify the following parties no later than twenty-four (24) hours after completing its External Review:

 Member;

 Member’s Physician;

 Member’s Authorized Representative, if any; and

 HPN.

The IRO shall then submit a written copy of its determination within forty-eight (48) hours to the applicable parties listed above.

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12.9 Office for Consumer Health Assistance

 (702) 486-3587 in Las Vegas area

 1-888-333-1597 outside of Las Vegas area (toll-free)

SECTION 13. Glossary

 “Adverse Benefit Determination” means a rescission of coverage; a decision by HPN to deny, reduce, terminate, fail to

provide, or make payment for a benefit, including a denial, reduction, termination, or failure to provide or make a payment

for a benefit that is based on:

 an individual’s eligibility;

 a determination that a benefit is not a Covered Service;

 the imposition of a limitation on an otherwise Covered Service; or

 a determination that a benefit is Experimental, Investigational or Unproven, or not Medically Necessary or appropriate.

External Review is only available for a Final Adverse Benefit Determination based on Medical Necessity, appropriateness,

health care setting, level of care, or effectiveness of a Covered Service. An Adverse Benefit Determination is final if the

Member has exhausted all complaint and Appeal Procedures set forth herein for the review of such Adverse Benefit

Determination.

 “Agreement of Coverage” or “AOC” means this document, including the Attachment A Benefit Schedule and any other

Attachments, Endorsements, Riders or Amendments to it, the Member’s Enrollment Form, health statements, Member

Identification Card, and all other applications received by HPN.

 “Alternate Facility” means a health care facility that is not a Hospital. It provides one or more of the following services on

an outpatient basis, as permitted by law:

 Surgical services.

 Emergency Services.

 Rehabilitative, laboratory, diagnostic or therapeutic services.

An Alternate Facility may also provide Mental Illness or Substance-Related and Addictive Disorders Services on an

Outpatient or Inpatient basis.

 “Ambulance” means a ground or air vehicle licensed to provide Ambulance services.

 “Ambulatory Surgical Facility” means a facility that:

 is licensed by the state where it is located.

 is equipped and operated mainly to provide for surgeries or obstetrical deliveries.

 allows patients to leave the facility the same day the surgery or delivery occurs.

 “Ancillary Services” means items and services provided by a Non-Plan Provider at a Plan facility that are any of the

following:

 related to emergency medicine, anesthesiology, pathology, radiology, and neonatology;

 provided by assistant surgeons, hospitalists, and intensivists;

 diagnostic services, including radiology and laboratory services, unless such items and services are excluded from the

definition Ancillary Services as determined by the Secretary;

 provided by such other specialty practitioners as determined by the Secretary; and

 provided by a Non-Plan Provider when no other Plan Provider is available.

 “Application Review Period” means the period of time that must pass before coverage for an individual or Eligible Family

Member can become effective. The Application Review Period begins on the date the individual submits a substantially

complete application for coverage and ends on the following:

 the date coverage begins if the application results in coverage; or

 the date on which the application is denied by HPN if the application does not result in coverage; or

 the date on which the offer for coverage lapses if the application does not result in coverage.

 “Applied Behavior Analysis” or “ABA” means the design, implementation and evaluation of environmental modifications

using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, but not

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limited to, the use of direct observation, measurement and functional analysis of the relations between environment and

behavior.

 “Authorized Representative” means a person designated by the Member to act on his behalf in pursuing a Claim for

Benefits, to file an appeal of an adverse determination or in obtaining an External Review of a final Adverse Benefit

Determination. The designation must be in writing unless the claim or appeal involves an Urgent Care Claim and a

healthcare professional with knowledge of the Member’s medical condition is seeking to act on the Member’s behalf as his

Authorized Representative.

 “Autism Spectrum Disorders” means a condition that meets the diagnostic criteria for autism spectrum disorder published

in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric

Association or the edition thereof that was in effect at the time the condition was diagnosed or determined.

 “Benefit Schedule” means the brief summary of benefits, limitations and Copayments given to the Subscriber by HPN. It is

Attachment A to this AOC.

 “Biosimilar Prescription Drug” means a biological Prescription Drug approved based on showing that it is highly similar to

a Reference Product, and has no clinically meaningful differences in terms of safety and effectiveness from the Reference

Product.

 “Blended Lenses” means bifocals which do not have a visible dividing line.

 “ Brand Name Drug” means a Prescription Drug which is marketed under or protected by:

 a registered trademark; or

 a registered trade name; or

 a registered patent.

 “Calendar Year” means January 1 through December 31 of the same year.

 “Calendar Year Out of Pocket Maximum” means the maximum amount of Out of Pocket expenses a Member is required

to pay for Covered Services in a Calendar Year, as outlined in the Attachment A, Schedule of Benefits. Once the Calendar

Year Out of Pocket Maximum is met, no further cost share is required for the remainder of the Calendar Year.

The Out of Pocket Maximum does not include any amounts:

 resulting from the Member’s failure to comply with HPN’s Managed Care Program, including the inappropriate use of

an emergency room facility for a condition which does not require Emergency Services;

 in excess of Eligible Medical Expenses, or the Recognized Amount when applicable,;

 for services that are not Covered Services;

 for services that are not Prior Authorized through HPN’s Managed Care Program; or

 in excess of the Calendar Year, per Illness or any other benefit maximums as set forth in Attachment A Benefit Schedule.

 “Claim For Benefits” means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s

Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests

for benefit payment).

 “COBRA” means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

 “Coated Lenses” means a substance which is added to a finished lens on one or both surfaces.

 “Coinsurance” means the percentage of the charges billed or the percentage of Eligible Medical Expenses, or the

Recognized Amount when applicable, whichever is less, that a Member must pay a Provider for Covered Services.

Coinsurance amounts are to be paid by the Member directly to the Provider who bills for the Covered Services. (See

Attachment A, Benefit Schedule.)

 “Complications of Pregnancy” means:

 conditions with diagnoses which are distinct from pregnancy but adversely affected by pregnancy or caused by

pregnancy. Such conditions include: acute nephritis, nephrosis, cardiac decompensation, hyperemesis gravidarum,

puerperal infection, toxemia, eclampsia, and missed abortion;

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 a non-elective cesarean section;

 terminated ectopic pregnancy; or

 spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.

Complications of Pregnancy does NOT include (1) false or premature labor; (2) occasional spotting; (3) prescribed rest

during the period of pregnancy; or (4) similar conditions associated with the management of a difficult or high risk pregnancy

not constituting a distinct Complication of Pregnancy.

 “Compound” means to form or create a Medically Necessary customized composite product by combining two (2) or more

different ingredients according to a Physician’s specifications to meet an individual patient’s need.

 “Contact Lenses” means ophthalmic corrective Lenses, either glass or plastic, ground or molded as prescribed by a Plan

Provider to be fitted directly to the patient’s eyes.

 “Convenient Care Facility” means a facility that provides services for Medically Necessary, non-urgent or non-emergent

injuries or illnesses. Examples of such conditions include:

 blood pressure checks;

 diagnostic laboratory services;

 general health screenings;

 minor illnesses (cold/flu);

 minor wound treatment and repair;

 treatment of burns and sprains.

 “Copayment” or “Cost-share” means the amount the Member pays at the time a Covered Service is received.

 “Covered Drug” means a Brand Name or Generic Prescription Drug or diabetic supply or equipment which:

 can only be obtained with a prescription;

 has been approved by the Food and Drug Administration (“FDA”) for general marketing;

 is dispensed by a licensed pharmacist; is prescribed by a Plan Provider, except in the case of Emergency Services and

Urgently Needed Services;

 is a Prescription Drug that does not have an over-the-counter Therapeutic Equivalent available;

 and is not specifically excluded herein.

 “Covered Services” means the health services supplies and accomodations, for which HPN pays benefits under this Plan.

 “Covered Transplant Procedures” means any Medically Necessary, human-to-human, organ or tissue transplants

performed upon a Member who satisfies medical criteria developed by HPN for receiving transplant services. It includes any

transplant procedures for which coverage is required by federal regulation.

 “Custodial Care” means care that mainly provides room and board (meals) for a physically or mentally disabled person.

Such care does not reduce the disability so that the person can live outside a Hospital or nursing home. Examples of

Custodial Care include:

 Non-Skilled Nursing Care.

 Supervisory care by a Physician in a custodial facility to meet regulatory requirements.

 Training or assistance in personal hygiene.

 Other forms of self-care.

 “Deductible” means the portion of Eligible Medical Expenses, or the Recognized Amount when applicable, excluding

Copayments, that a Member must pay, either in the aggregate or for a particular service, before HPN will make any benefit

payments for Covered Services. (See Attachment A Benefit Schedule.)

 “Dentist” means anyone qualified and licensed to practice dentistry who has a degree of Doctor or Dental Surgery (D.D.S.) or

Doctor of Medical Dentistry (D.M.D.).

 “Dental Director” means a Dentist designated by HPN to review the utilization of dental services by Members.

 “Dependent” means an Eligible Family Member of the Subscriber's family who:

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 meets the eligibility requirements of the Plan as set forth in Section 1 of this AOC;

 is enrolled under this Plan; and

 for whom premiums have been received and accepted by HPN.

 “Designated Plan Pharmacy” means a pharmacy that has entered into an agreement with HPN to provide specific Covered

Drugs and/or supplies to Members. The fact that a pharmacy is a Plan Pharmacy does not mean that it is a Designated Plan

Pharmacy. For the purposes of the Prescription Drug Benefit, please refer to the HPN PDL on the website or contact Member

Services for the specific Designated Plan Pharmacy for your Covered Drug and/or supply/equipment.

 “Dispensing Period” as established by HPN means 1) a predetermined period of time; or 2) a period of time up to a

predetermined age attained by the Member that a specific Covered Drug is recommended by the FDA to be an appropriate

course of treatment when prescribed in connection with a particular condition.

 “Durable Medical Equipment” or “DME” means medical equipment that:

 can withstand repeated use;

 is used primarily and customarily for a medical purpose rather than convenience or comfort;

 generally is not useful to a person in the absence of an Illness or Injury;

 is appropriate for use in the home; and

 is prescribed by a Physician.

 “Effective Date” means the initial date on which Members are covered for services under this Plan provided any applicable

premiums have been received and accepted by HPN.

 “Eligible Dental Expenses” (“EDE”) means the maximum amount HPN will pay for a particular Covered Service as

determined by HPN in accordance with HPN Reimbursement Schedule. Dental Plan Providers have agreed to accept HPN’s

reimbursement as payment in full for Covered Services, less any applicable Copayment. Deductible or Coinsurance. In no

event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule.

 “Eligible Family Member” means a member of a Subscriber’s family that is or becomes eligible to enroll for coverage

under this Plan as a Dependent.

 “Eligible Medical Expenses” or “EME” means the maximum amount HPN will pay for a particular Covered Service as

determined by HPN in accordance with HPN’s Reimbursement Schedule or determined as required by law

 “Eligible Vision Expenses” (EVE) means the maximum allowable amount the Company will pay for a particular Covered

Service as determined by the Company in accordance with the HPN Reimbursement Schedule. Vision Plan Providers have

agreed to accept the HPN Reimbursement Schedule as payment in full for Covered Services, less any applicable Copayment.

In no event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule.

 “Emergency Dental Services” means Covered Services provided after the sudden onset of a dental condition involving the

teeth and supporting tissues with symptoms severe enough to cause a prudent person to believe that there is an immediate

need to be treated by a relevant professional.

 “Emergency Services” means Covered Services provided for a medical condition with symptoms severe enough to cause a

prudent person to believe that lack of immediate medical attention at a Hospital or Emergency department could result in

serious:

 jeopardy to his health;

 jeopardy to the health of an unborn child;

 impairment of a bodily function; or

 dysfunction of any bodily organ or part.

Emergency Services include items and services otherwise covered by HPN when provided by a Non-Plan Provider or facility

(regardless of the department of the Hospital in which the items and services are provided) after the patient is stabilized and as

part of outpatient observation, or an inpatient or outpatient stay that is connected to the original Emergency, unless each of the

following conditions are met:

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 The provider or facility, as described above, determines the patient is able to travel using nonmedical transportation or

non-Emergency medical transportation.

 The provider furnishing the additional items and services satisfies notice and consent criteria in accordance with applicable

law.

 The patient is in such a condition to receive information as stated in b) above and to provide informed consent in

accordance with applicable law.

 Any other conditions as specified by the Secretary.

 “Enrollment Date” means the first day of coverage under this Plan or, if there is a Waiting Period, the first day of the

Waiting Period.

 “ERISA” means Employee Retirement Income Security Act of 1974, as amended, including regulations implementing the

Act.

 “Essential Benefits” include the following: ambulatory services; Emergency Services; hospitalization; maternity and

newborn care; mental health and substance abuse disorder services (including behavioral health treatment); prescription

drugs; rehabilitative and Habilitative Services and devices; laboratory services; preventive and wellness services and chronic

disease management; and pediatric services; including oral and vision care.

Such benefits shall be consistent with those set forth under the Patient Protection and Affordable Care Act of 2010 and any

regulations issued pursuant thereto.

 “Expedited Appeal” means a Member appeals a decision regarding a denied request for Prior Authorization (Pre-Service

Claim) for an Urgent Care Claim, the Member or Member’s Authorized Representative can request an Expedited Appeal,

either orally or in writing. Decisions regarding an Expedited Appeal are generally made within seventy-two (72) hours from

the Plan’s receipt of the request.

 “Experimental or Investigational” means medical, surgical, diagnostic, psychiatric, mental health, substance-related and

addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications

or devices that, at the time HPN makes a determination regarding coverage in a particular case, are determined to be any of

the following:

 Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not

identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as

appropriate for the proposed use.

 Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved

under the Humanitarian Use Device exemption are not Experimental or Investigational.)

 The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III clinical trial set forth in the FDA

regulations, regardless of whether the trial is actually subject to FDA oversight.

Exceptions:

 Clinical trials for which benefits are available as described herein.

 HPN may, as we determine, consider an otherwise Experimental or Investigational service to be a covered

healthcare service for that illness or condition if:

 The Member is not a participant in a qualifying clinical trial, as herein: and

 The Member has an illness or condition that is likely to cause death within one year of the request for

treatment.

Prior to such a consideration, HPN must first establish that there is sufficient evidence to conclude that, even though

unproven, the service has significant potential as an effective treatment for that illness or condition.

 “External Review” means an independent review of an Adverse Benefit Determination conducted by an External Review

Organization.

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 “Family Members” means members of the Subscriber’s family who meet the eligibility requirements of the Agreement and

are enrolled according to the terms of the Agreement and for whom premiums have been received by HPN. For the purposes

of this Agreement, Family Members may also be referred to as “Dependents”.

 “Final Adverse Benefit Determination” means the upholding of an Adverse Benefit Determination at the conclusion of the

internal appeals process or an Adverse Benefit Determination in which the internal appeals process has been deemed

exhausted.

External Review is only available for a Final Adverse Benefit Determination based on Medical Necessity, appropriateness,

health care setting, level of care, or effectiveness of a Covered Service.

 “Frames” means standard eyeglass Frames adequate to hold two Lenses.

 “Free Standing Diagnostic Center” means a licensed establishment which has permanent facilities that are equipped and

operated primarily for the purpose of performing outpatient diagnostic services.

 “Free Standing Emergency Facility” means a facility, structurally separate and distinct from a hospital, which provides

limited services for the treatment of a medical emergency and licensed as ascribed in NAC 449.61032 – NAC 449.61384.

 “Gender Dysphoria” means a disorder characterized by diagnostic criteria classified in the current edition of the Diagnostic

and Statistical Manual of the American Psychiatric Association.

 “Generic Drug” means an FDA-approved Prescription Drug which does not meet the definition of a Brand Name Drug as

defined herein.

 “Genetic Disease Testing” means the analysis of human DNA, chromosomes, proteins or other gene products to determine

the presence of disease related genotypes, mutations, phenotypes or karyotypes for clinical purposes. Such purposes include

those tests meeting criteria for the medically accepted standard of care for the prediction of disease risks, identification of

carriers, monitoring, diagnosis or prognosis, but do not include tests conducted purely for research.

 “Health Benefit Plan” means a policy, contract, certificate or agreement offered by a carrier, or similar agreement offered

by an employer or other legal entity, to provide for, arrange for payment of, pay for or reimburse any of the costs of

healthcare services. This term includes Short-Term and catastrophic health insurance policies, and a policy that pays on a

cost-incurred basis. Health Benefit Plans do not include:

 Coverage for accident only, dental only, vision only, disability income insurance, long-term care only insurance, hospital

indemnity coverage or other fixed indemnity coverage, limited benefit coverage, specific disease/Illness coverage, credit-

only insurance;

 Coverage issued as a supplement to liability insurance;

 Liability insurance, including general liability insurance and automobile liability insurance;

 Workers’ compensation insurance;

 Coverage for medical payments under a policy of automobile insurance;

 Coverage for on-site medical clinics; or

 Medicare supplemental health insurance.

 “Health Maintenance Organization” or “HMO” means an organization that is formed in accordance with state law to

provide managed healthcare services.

 “Health Plan of Nevada” or “HPN” means Health Plan of Nevada, Inc., a Nevada corporation licensed by the Nevada

Insurance Commissioner under Nevada law. HPN is a federally qualified Health Maintenance Organization.

 “HPN Reimbursement Schedule” means the schedule showing the amount HPN will pay for Eligible Medical Expenses, or

the Recognized Amount when applicable, (EME) to Providers and will be applicable to Non-Plan Providers including Non-

Plan Facilities. HPN Reimbursement Schedule is based on:

 the amount most consistently paid to the Provider; or

 the amount paid to other Providers with the same or similar qualifications; or

 the relative value and worth of the service compared to other services which HPN determines to be similar in complexity

and nature with reference to other industry and governmental sources, examples of these sources include published rates

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allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar services within the

geographic market, a gap methodology, or Eligible Medical Expenses, or Recognized Amount when applicable, could be

based on a percentage of the provider’s billed charge.

For Non-Plan Provider Emergency Services, HPN will pay the greater of:

 the amount we have negotiated with Plan Providers for the Emergency Services received (and if there is more than one

amount, the median of the amounts); or

 100% of the Eligible Medical Expenses, or Recognized Amount when applicable, for Emergency Services provided by a

Non-Plan Provider under your Plan; or

 the amount that would be paid for the Emergency Services under Medicare.

 “Home Healthcare” means healthcare services given by a Home Healthcare agency, under a Physician’s orders in the

person’s home. It is care given to persons who are homebound for medical reasons and physically not able to obtain

necessary medical care on an outpatient basis. A Home Healthcare agency must be licensed by the state where it is located.

 “Hospice” means an establishment licensed by the state where it is located that furnishes a centrally administered program of

palliative and supportive services. Such services are provided by a team of healthcare Providers and directed by a Physician.

Services include physical, psychological, custodial and spiritual care for patients who are terminally ill and their families.

For the purposes of this benefit only, "family" includes the immediate family, the person who primarily cared for the patient

and other persons with significant personal ties to the patient, whether or not related by blood.

 “Hospice Care Services” means acute care provided by a Hospice if the Member has less than six (6) months to live as

certified by the treating Physician, and the Member is not receiving or intending to receive any curative treatment. Care may

be provided in the home, at a residential facility or at a medical facility at any time of the day or night. These services

include bereavement care provided to the patient’s family after the patient dies.

 “Hospital” means a facility that:

 is licensed by the state where it is located and is Medicare-certified;

 provides 24-hour nursing services by registered nurses (RNs) on duty or call; and

 provides services under the supervision of a staff of one or more Physicians to diagnose and treat ill or injured bed

patients hospitalized for surgical, medical or psychiatric conditions.

Hospital does not include:

 Ambulatory Surgical Facilities

 Christian Science sanataria;

 Free Standing Emergency Facilities;

 health resorts;

 institutions for exceptional children;

 nursing homes;

 Residential Treatment Centers;

 Physician offices;

 private homes; or

 Skilled Nursing Facilities, places that are primarily for the care of convalescents.

 “Illness” means an abnormal state of health resulting from disease, sickness or malfunction of the body; or a congenital

malformation which causes functional impairment. For purposes of this AOC, Illness also includes sterilization or

circumcision. Illness does not include any state of mental health or mental disorder other than Mental Illness as it is defined

in this AOC.

 “Independent Review Organization” means an entity that:

 Conducts an independent External Review of an adverse determination; and

 Is certified by the Nevada Commissioner of Insurance

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 “Initial Enrollment Period” means the period of time during which an eligible person may enroll under this Plan.

 “Injury” means physical damage to the body inflicted by a foreign object, force, temperature, or corrosive chemical.

 “Inpatient” means being confined in a Hospital, Skilled Nursing Facility or Residential Treatment Center as a registered bed

patient under a Physician's order.

 “Lenses” mean ophthalmic corrective Lenses, either glass or plastic, ground or molded as prescribed by a Vision Plan

Provider to be fitted into frames.

 “Licensed Assistant Behavior Analyst” means a person who holds current certification as a Board Certified Assistant

Behavior Analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization,

who is licensed as an assistant behavior analyst by the Aging and Disability Services Division of the Department of Health

and Human Services and who provides behavioral therapy under the supervision of a licensed behavior analyst or

psychologist.

 “Licensed Behavior Analyst” means a person who holds current certification as a Board Certified Behavior Analyst issued

by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization and is licensed as a

behavior analyst by the Aging and Disability Services Division of the Department of Health and Human Services.

 Low Vision” means a significant loss of vision but not total blindness.

 “Mail Order Plan Pharmacy” means a duly licensed pharmacy that has an independent contractor agreement with HPN to

provide certain Covered Drugs to Members by mail.

 “Managed Care Program” means the process that determines Medical Necessity and directs care to the most appropriate

setting to provide quality care in a cost-effective manner, including Prior Authorization of certain services.

 “Manual Manipulation” means the diagnosis, treatment or maintenance by a Practitioner for the treatment of:

 musculoskeletal strain surrounding vertebra, spine, broken neck; or

 subluxation of verterbra.

Manual Manipulation does not include diagnosis or treatment requiring general anesthesia, surgery or Hospital confinement.

 “Medical Director” means a Physician named by HPN to review use of health services by Members.

 “Medically Necessary” means a service needed to improve a specific health condition or to preserve the Member’s health

and which, as determined by HPN is:

 consistent with the diagnosis and treatment of the Member’s Illness or Injury;

 the most appropriate level of service which can be safely provided to the Member; and

 not solely for the convenience of the Member, the Provider(s) or Hospital.

In determining whether a service or supply is Medically Necessary, HPN may give consideration to any or all of the

following:

 the likelihood of a certain service or supply producing a significant positive outcome;

 reports in peer-review literature;

 evidence based reports and guidelines published by nationally recognized professional organizations that include

supporting scientific date;

 professional standards of safety and effectiveness that are generally recognized in the United States for diagnosis, care or

treatment;

 the opinions of independent expert Physicians in the health specialty involved when such opinions are based on broad

professional consensus; or

 other relevant information obtained by HPN.

When applied to Inpatient services, “Medically Necessary” further means that the Member’s condition requires treatment in a

Hospital rather than in any other setting. Services and accommodations will not automatically be considered Medically

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Necessary simply because they were prescribed by a Physician.

 “Medically Necessary for External Review” means healthcare services or products that a prudent Physician would provide

to a patient to prevent, diagnose or treat an Illness, Injury or disease or any symptoms thereof that are necessary and:

 provided in accordance with generally accepted standards of medical practice;

 clinically appropriate with regard to type, frequency, extent, location and duration;

 not primarily provided for the convenience of the patient, Physician or other Provider of healthcare;

 required to improve a specific health condition of a Member or to preserve his existing state of health; and

 the most clinically appropriate level of healthcare that may be safely provided to the Member.

 “Medicare” means Medicare Part A or Medicare Part B healthcare benefits that a Member is receiving under Title XVIII of

the Social Security Act of 1965 as amended.

 “Member” means a person who meets the eligibility requirements of Section 1, who has enrolled under this Plan and for

whom premiums have been received and accepted by HPN.

 “Mental Health Professional” means any person qualified and licensed to provide assessments, diagnosis and therapy for

mental health conditions or substance use disorders.

 “Mental Illness” means a pathological state of mind producing clinically significant psychological or physiological

symptoms together with impairment in one or more major areas of functioning where improvement can reasonably be

anticipated with therapy. Mental Illness does not include any Severe Mental Illness as defined in the AOC and otherwise

covered under the Severe Mental Illness Covered Services section, or any of the following when they represent the primary

need for therapy:

 behavior disorders;

 chronic organic brain syndrome;

 learning disabilities;

 marital or family problems;

 intellectual disability;

 personality disorder; or

 social, occupational, or religious maladjustment.

 “Minimum Essential Coverage (MEC)” means any insurance plan that meets the Affordable Care Act requirement for

having health coverage. Examples of plans that qualify include:

 job-based plans;

 Marketplace plans;

 Medicare; and

 Medicaid & CHIP.

 “Non-Medical 24-Hour Withdrawal Management” – means sn organized residential service, including those defined in

American Society of Addiction Medicine (ASAM) criteria, providing 24-hour supervision, observation, and support for

patients who are intoxicated or experiencing withdrawal, using peer and social support rather than medical and nursing care.

 “Non-Plan Pharmacy” means a duly licensed pharmacy that does not have an independent contractor agreement with HPN

to provide Covered Drugs to Members.

 “Non-Plan Provider” means a Provider who does not have an independent contractor agreement with HPN.

 “Occupational” with respect to any Illness or Injury means any Illness or Injury arising out of or in the course of

employment for pay or profit.

 “Orthoptics” means the teaching and training process for the improvement of visual perception and coordination of the two

eyes for efficient and comfortable binoncular vision.

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 “Orthotic Device” means an apparatus used to support, align, prevent or correct deformities or to improve the function of

movable parts of the body.

 “Oversize Lenses” means large than standard lens blank, to accommodate prescriptions.

 “Photochromic Lenses” means lenses which change color with intensity of sunlight.

 “Physician” means anyone qualified and licensed to practice medicine and surgery by the state where the practice is located

who has the degree of Doctor of Medicine (MD) or Doctor of Osteopathy (DO). Physician also means doctors of Dentistry

and Podiatric Medicine or a Chiropractor when they are acting within the scope of their license.

 “Physician-assisted Suicide” means a physician facilitates a patient’s death by providing the necessary means and/or

information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information

about the lethal dose, while aware that the patient may commit suicide).

 “Physician Extender/Physician Assistant” means a healthcare 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.

 “Placed (or Placement) for Adoption” means the assumption and retention of a legal obligation for total or partial support

of a child by a person with whom the child has been placed in anticipation of the child’s adoption. The child’s Placement for

Adoption with such person ends upon the termination of such legal obligation.

 “Plan” means this Agreement of Coverage (AOC), including the Attachment A Benefit Schedule and any other Attachments,

Endorsements, Riders or Amendments to it, the Member’s Enrollment Form, health statements, the Member Identification

Card, and all other applications received by HPN.

 “Plano Lenses” means lenses which have no refractive power.

 “Plan Pharmacy” means a duly licensed pharmacy that has an independent contractor agreement with HPN to provide

Covered Drugs to Members. Plan Pharmacy services are retail services only.

 “Plan Provider” means a Provider who has an independent contractor agreement with HPN to provide certain Covered

Services to Members. A Plan Provider’s agreement with HPN may terminate, and a Member will be required to select

another Plan Provider.

 “Post-Service Claim” means any Claim for Benefits under a Health Benefit Plan regarding payment of benefits that is not

considered a Pre-Service Claim or an Urgent Care Claim.

 “Practitioner” means any person(s) qualified and licensed to practice the healing arts when they are acting within the scope

of their license.

 “Prescription Drug” means a Federal legend drug or medicine that can only be obtained by a prescription order or that is

restricted to prescription dispensing by state law. It also includes insulin and glucagon.

 “Prescription Drug List (PDL)” means a list of FDA approved Generic and Brand Name Prescription Drugs established,

maintained, and recommended for use by HPN.

 “Pre-Service Claim” means any Claim for Benefits under a Health Benefit Plan with respect to which the terms of the Plan

condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

 “Primary Care Physician” or “PCP” means a Plan Provider who has an independent contractor agreement with HPN to

assume responsibility for arranging and coordinating the delivery of Covered Services to Members. A Primary Care

Physician’s agreement with HPN may terminate. In the event that a Member’s Primary Care Physician’s agreement

terminates, the Member will be required to select another Primary Care Physician.

 “Prior Authorization” or “Prior Authorized” means a system that requires a Provider to get approval from HPN before

providing non-emergency healthcare services to a Member in order for those services to be considered Covered Services.

Prior Authorization is not an agreement to pay for a service.

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 “Procurement” means obtaining Medically Necessary human organs or tissue for a Covered Transplant Procedure as

determined by HPN and includes donor search, testing, removal, preservation and transportation of the donated organ or

tissue. Procurement will also apply to medically appropriate donor testing services including, but not limited to, HLA typing,

subject to any maximum procurement benefit amount. Procurement does not include maintenance of a donor while the

Member is awaiting the transplant.

 “Professional Vision Services” means examination, material selection, fitting of glasses, related adjustments, etc.

 “Prosthetic Device” means a non-experimental device that replaces all or part of an internal or external body organ or

replaces all or part of the function of a permanently inoperative or malfunctioning internal or external organ.

 “Provider” means a:

 Ambulatory Surgical Facility;

 Dentist;

 Hospital;

 Physician;

 Practitioner;

 Podiatrist;

 Skilled Nursing Facility;

 Urgent Care Facility, or

 other person or organization licensed by the state where his/the practice is located to provide medical or surgical

services, supplies, and accommodations acting within the scope of his/the license.

 “Recognized Amount” means the amount which the Copayment, Coinsurance and any applicable CYD, is based on for the

below Covered Services when provided by Non-Plan Providers. The amount is based on either:

 Applicable state law, or

 The qualifying payment amount as determined under applicable law for the following Covered Services:

o Non-Plan Emergency Covered Services.

o Non-Emergency Covered Services received at certain Plan facilities by Non-Plan Providers, when such services

are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of

section 2799B-2(d) of the Public Service Act. For the purpose of this provision, "certain Plan facilities" are

limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical

access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center described in

section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Note: Covered Services that use the Recognized Amount to determine the Member cost sharing may be higher or

lower than if cost sharing for these Covered Services were determined based upon the Eligible Medical Expenses.

 “Reference Product” means a biological Prescription Drug.

 “Referral” means a recommendation for a Member to receive a service or care from another Provider or facility.

 “Residential Treatment Center” means a sub-acute facility or acute care facility which delivers twenty-four (24) hours,

seven (7) days a week assessment, diagnostic services and active behavioral health treatment to Members. The level of care

and length of stay, in a facility with the appropriate licensure level, is authorized through the HPN Managed Care program.

 “Retrospective” or “Retrospectively” means a review of an event after it has taken place.

 “Rider” means a provision added to the agreement or the AOC to expand benefits or coverage.

 “Secretary” means as that term is applied in the No Surprises Act of the Consolidated Appropriations Act (P.L. 116-260).

 “Service Area” means the geographical area where HPN is licensed to operate. It is shown in Attachment B. Subscribers

must physically live in the Service Area to be covered under this Plan. Dependent children that are covered under this Plan,

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due to a court order, do not have to reside within the Service Area.

 “Severe Mental Illness” means any of the following Mental Illnesses that are biologically based and for which diagnostic

criteria are prescribed in the Diagnostic and Statistical Manual of Mental Disorder (DSM), fourth edition, published by the

American Psychiatric Association:

 Bipolar disorder;

 Major depressive disorders;

 Obsessive-compulsive disorder;

 Panic disorder;

 Schizoaffective disorder; and

 Schizophrenia.

 “Short-Term” means the time required for treatment of a condition that, in the judgment of the Member's PCP and HPN, is

subject to significant improvement within sixty (60) consecutive calendar days from the first day of treatment.

 "Short-Term Habilitation Services" means occupational therapy, physical therapy and speech therapy prescribed by the

Member's treating Physician pursuant to a treatment plan to develop a function not currently present as a result of a

congenital, genetic, or early acquired disorder.

 A "congenital or genetic disorder" includes, but is not limited to, hereditary disorders.

 An "early acquired disorder" refers to a disorder resulting from Sickness, Injury, trauma or some other event or condition

suffered by a Member prior to that Member developing functional life skills such as, but not limited to, walking, talking,

or self-help skills.

 “Short-Term Rehabilitation” means Inpatient or outpatient rehabilitation services which are provided within the applicable

number of visits as set forth in the Plan’s Attachment A Benefit Schedule. This includes speech therapy, occupational

therapy and physical therapy.

 “Skilled Nursing Care” means services requiring the skill, training or supervision of licensed nursing personnel.

 “Skilled Nursing Facility” means a facility or distinct part of a facility that is licensed by the state where it is located to

provide Skilled Nursing Care instead of hospitalization and that has an attending medical staff consisting of one or more

Physicians.

 “Specialist Physician” or “Specialist” means a Plan Provider who has an independent contractor agreement with HPN to

assume responsibility for the delivery of specialty medical services to Members. These specialty medical services include

any Physician services not related to the ongoing primary care of a patient. A Specialist Physician’s agreement with HPN

may terminate. In the event that a Member’s Specialist Physician’s agreement terminates, another Specialist Physician will

be selected for the Member if those services are still required.

 “Specialty Drugs” are high-cost oral, injectable, infused or inhaled Covered Drugs as identified by HPN’s P&T Committee

that are either self-administered or administered by a healthcare Provider and used or obtained in either an outpatient or home

setting.

 “Step Therapy” is a program for Members who take Prescription Drugs for an ongoing medical condition, such as arthritis,

asthma or high blood pressure, which ensures the Member receives the most appropriate and cost-effective drug therapy for

their condition. The Step Therapy program requires that before benefits are payable for a high cost Covered Drug that may

have initially been prescribed, the Member try a lower cost first-step Covered Drug. If the prescribing Physician has

documented with HPN why the Member’s condition cannot be stabilized with the first-step Covered Drug, HPN will review

a request for Prior Authorization to move the Member to a second-step drug, and so on, until it is determined by HPN that the

prescribed Covered Drug is Medically Necessary and eligible for benefit payment.

 “Subscriber” means an individual who meets the eligibility requirements of this Plan, and who has enrolled under the Plan,

and for whom premiums have been received and accepted by HPN.

 “Substance-Related and Addictive Disorder” as defined in the Diagnostic and Statistical Manual of Mental Disorder

(DSM), fifth edition, is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual

continues using the substance despite significant substance-related problems. Substance-Related and Addictive Disorder

treatment:

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 must be provided as a part of a treatment plan with clearly defined goals that are realistic and measurable. The plan must

address significant impairment or deterioration in the member’s occupational or scholastic function, social function, or

ability to provide self-care.

 must be provided by state licensed professionals who are practicing within the scope of this licensure.

 “Summary of Benefits” (“SBC”) means a concise document detailing, in plain language, simple and consistent information

about health plan benefits and coverage. The SBC helps consumers better understand the coverage they have and allow them

to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered

benefits, cost-sharing provisions and coverage limitations and exceptions. Members will receive the summary when

shopping for coverage, enrolling in coverage, at each new plan year and within seven business days of requesting a copy

from their insurance issuer or group health plan.

 “Telemedicine” means the delivery of Covered Services from a provider of health care to a patient at a different location

through the use of information and audio-visual communication technology, not including

facsimile or electronic mail. The term includes, without limitation, the delivery of services from a provider of health

care to a patient at a different location through the use of:

 Synchronous interaction or an asynchronous system of storing and forwarding information; and

 Audio-only interaction, whether synchronous or asynchronous.

 “Therapeutic Equivalent” means that a Covered Drug can be expected to produce essentially the same therapeutic outcome

and toxicity.

 “Therapeutic Supply” is the maximum quantity of supplies for which benefits are available for a single applicable

Copayment or Coinsurance amount, if applicable, and may be less than but shall not exceed a thirty (30) day supply.

 “Tinted Lenses” means lenses which have additional substance added to produce constant tint (e.g., pink, green, gray, blue,

etc.).

 “Transitional Living” means Mental Health Care Services and Substance-Related and Addictive Disorders Services

provided through facilities, group homes and supervised apartments which provide twenty-four (24) hour supervision,

including those defined in the American Society of Addiction Medicine (ASAM) Criteria, and are either:

 Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. They provide stable and safe

housing, an alcohol/drug-free environment and support for recovery. They may be used as an addition to ambulatory

treatment when it doesn't offer the intensity and structure needed to help you with recovery.

 Supervised living arrangements which are residences such as facilities, group homes and supervised apartments. They

provide stable and safe housing and the opportunity to learn how to manage activities of daily living. They may be used

as an addition to treatment when it doesn't offer the intensity and structure needed to help with recovery.

 “Transplant Benefit Period” means the period beginning with the date the Member receives a written Referral from HPN

for care in a Transplant Facility and ending on the first of the following to occur:

 the date 365 days after the date of the transplant; or

 the date when the Member is no longer covered under this Plan.

 “Transplant Facility” means a Hospital that has an independent contractor agreement or other contractual relationship with

HPN to provide Covered Services to Eligible Members in connection with organ or tissue transplants related to a Covered

Transplant Procedure as defined in this AOC. Non-Plan Hospitals do not have any contractual relationship with HPN to

provide such services.

 “Unproven” in the context of “Experimental, Investigational or Unproven”, means services, including medications, that are

not determined to be effective for treatment of the medical condition or not determined to have a beneficial effect on health

outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort

studies in the prevailing published peer-reviewed medical literature.

 Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not

allowed to choose which treatment is received.)

 Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are compared to a

group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment

group.)

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HPN has a process by which we compile and review clinical evidence with respect to certain health care services. From time

to time, HPN will issue medical and drug policies that describe the clinical evidence available with respect to specific health

care services. These medical and drug policies are subject to change without prior notice. The Member can view these

policies at https://healthplanofnevada.com/Provider/Medical-Policies

NOTE: If a Member has a life-threatening illness or condition (one that is likely to cause death within one year of the request

for treatment) HPN may, as we determine, consider an otherwise unproven service to be a covered healthcare service for that

illness or condition. Prior to such a consideration, HPN must first establish that there is sufficient evidence to conclude that,

even though Unproven, the service has significant potential as an effective treatment for that illness or condition.

 “Urgent Care Claim” means a Claim for Benefits that is treated in an expedited manner because the application of the time

periods for making determinations that are not Urgent Care Claims could seriously jeopardize the Member’s life, health or

the ability to regain maximum function by waiting for a routine appeal decision. An Urgent Care Claim also means a Claim

for Benefits that, in the opinion of a Physician with knowledge of the Member’s medical conditions, would subject the

Member to severe pain that cannot be adequately managed without the care or the treatment that is the subject of the claim.

If an original request for Prior Authorization of an Urgent Care service was denied, the Member could request an Expedited

Appeal for the Urgent Care Claim.

 “Urgent Care Facility” means a facility equipped and operated mainly to give immediate treatment for an acute Illness or

Injury.

 “Urgently Needed Services” means Covered Services needed to prevent a serious deterioration in a Member’s health. While

not as immediate as Emergency Services, these services cannot be delayed until the Member can see a Plan Provider.

 “Vision Plan Provider” means a Provider who has an independent contractor agreement with HPN to provide certain

Covered Services to Members. A Vision Plan Provider’s agreement with HPN may terminate, and a Member will be

required to select another Vision Plan Provider.