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PEBP CONSUMER DRIVEN HEALTH PLANMASTER PLAN DOCUMENTPLAN YEAR 2021(EFFECTIVE JULY 1, 2020 – JUNE 30, 2021)Public Employees’ Benefits Program901 S. Stewart Street, Suite 1001Carson City, Nevada 89701(775) 684-7000 (800) 326-5496

CDHP Plan Year 2021Table of ContentsAmendment Log. 1Welcome PEBP Participant . 2Introduction . 3Suggestions for Using this Document: . 4Accessing Other Benefit Information: . 4Participant Rights and Responsibilities . 5You have the right to: . 5You have the responsibility to: . 5The plan is committed to: . 6Summary of the CDHP Components . 6Highlights of the Plan . 6Deductibles . 7In-Network Individual Deductible . 7Out-of-Network Individual Deductible . 8In-Network Family Deductible . 8Out-of-Network Family Deductible. 8Coinsurance. 9Out-of-Pocket Maximums . 9In-Network Out-of-Pocket Maximums . 9Out-of-Network Out-of-Pocket Maximum . 10Description of In-Network and Out-of-Network . 10Provider Network . 10In-Network Provider/Benefits . 11Out-of-Network Provider/Benefits . 11Other Providers . 12Out-of-Network Benefits Exceptions . 12Travel . 12Emergency Care . 12Confinement in an out-of-network hospital following an emergency . 12Other Exceptions . 13When Out-of-Network Providers May be Paid as In-Network Providers . 13In-State Preferred Provider Organizations (PPO Network) . 13Out-of-State Preferred Provider Organizations (PPO Network) . 13Service Area . 142

CDHP Plan Year 2021Directories of Network Providers . 14Eligible Medical Expenses . 14A Person Whose Status Changes from Employee/Retiree to Dependent or from Dependent to Employee . 15Non-Eligible Medical Expenses. 15PPO Network Health Care Provider Services . 15Out-of-Country Medical, Prescription and Vision Purchases . 16Healthcare Bluebook Pricing Tool . 17Healthcare Bluebook Incentive Reward . 18Health Savings Accounts . 18Active Employees Only . 18Health Savings Account Owner Identity Verification . 20HSA Contributions for Eligible Active Employees . 20Calendar Year 2020 HSA Contribution Limits . 20Health Reimbursement Arrangement . 20Active Employees and Retirees . 21Timely Filing of HRA Claims . 22HRA Contributions for Eligible Active Employees and Retirees. 22Utilization Management . 23Concurrent Review . 24Retrospective Review . 25Case Management . 25Precertification (Prior Authorization) . 25How to Request Precertification (Prior Authorization) . 28Elective Inpatient and Outpatient Surgeries . 28Outpatient Infusion Services Performed at Exclusive Hospitals and Infusion Centers . 28Emergency Hospitalization . 29Gender Reassignment Surgery . 29Inpatient and Out-Patient Surgery Performed at Exclusive Hospitals and Out-Patient Surgery Centers . 29Failure to Follow Required UM Procedures . 29Coronavirus (COVID-19) Pandemic Benefits . 31Schedule of Medical Benefits . 32Acupuncture . 32Allergy Services . 32Ambulance . 33Autism Spectrum Disorders Services . 35Bariatric/Weight Loss Surgery . 35Behavioral Health Services . 383

CDHP Plan Year 2021Blood Transfusions . 39Chemotherapy . 40Chiropractic Services. 40Clinical Trials . 41Corrective Appliances . 41Diabetes Care Management Disease Program (Enhanced Benefits)* . 42Diabetes Education Services . 44Dialysis . 45Durable Medical Equipment (DME) . 46Emergent and Urgent Care Services . 47Fertility, Sexual Dysfunction Services and Male Contraception . 48Gender Reassignment Surgery for the treatment of Gender Dysphoria . 48Genetic Testing and Counseling. 51Home Health Care and Home Infusion Services . 52Hospice . 53Hospital Services (Inpatient) . 53Laboratory Outpatient Services . 54Maternity Services . 56Nondurable Supplies. 57Obesity and Overweight Care Disease Management Program (Enhanced Benefits)* . 57Oral and Craniofacial Services . 61Outpatient Surgery Facility . 62Physician and Other Health Care Practitioner Services . 63Preventive Care/Wellness Benefits . 64Radiology (X-Ray), Nuclear Medicine & Radiation Therapy Services (Outpatient) . 69Reconstructive Services and Breast Reconstruction after Mastectomy . 69Rehabilitation Services (Cardiac) . 71Rehabilitation Services (Physical, Occupational, and Speech Therapy) . 71Second Physician Opinion . 72Skilled Nursing Facility (SNF) and Subacute Care Facility . 72Special Food Products for Inherited Metabolic Disorders . 722nd.MD (Second Opinion Service) . 73Telemedicine . 73Transplants (Organ and Tissue) . 74Travel Expenses . 75Vision Screening Exam* . 78Schedule of Prescription Drug Benefits . 79Preventive Medications . 79Exclusions . 88CDHP Medical Claims Administration . 98How Medical Benefits are Paid . 98How to File a Medical Claim . 99Where to Send the Claim Form . 100Appeals . 100Medical and Dental Claims and HRA Appeals . 101Written Notice of Adverse Benefit Determination . 1014

CDHP Plan Year 2021Appealing a Utilization Management Determination . 103Internal UM Appeals Reviews . 103External UM Appeal Reviews . 104Experimental and/or Investigational Claim/UM External Review . 105Prescription Drug Review and Appeals . 106Clinical Coverage Review . 106How to Request a Clinical Coverage Review . 106Administrative Coverage Review . 106How to Request an Administrative Coverage Review . 106Level 1 Appeal or Urgent Appeal . 107Level 2 Appeal . 108External Reviews . 108Coordination of Benefits . 109Which Benefits are Subject to Coordination? . 109When and How Coordination of Benefits (COB) Applies . 110Which Plan Pays First: Order of Benefit Determination Rules. 111Administration of COB . 113Coordination with Medicare . 114Entitlement to Medicare Coverage (Retirees and their Covered Dependents) . 114Retirees Ineligible for Premium-Free Medicare Part A . 115Coverage under Medicare and This Plan when You Have End-Stage Renal Disease (ESRD) . 115How Much This Plan Pays When It Is Secondary to Medicare . 115Coordination with Other Government Programs . 116Medicaid . 116Coordination with Medicare . 116Tricare . 116Veterans Affairs Facility Services . 116Worker’s Compensation . 116Disability . 117Prescription Drug Plan . 117Subrogation and Third-Party Recovery. 117Participant Contact Guide . 119Key Terms and Definitions . 1225

Amendment LogAmendment LogAny amendments, changes or updates to this document will be listed here. The amendment log willinclude what sections are amended and where the changes can be found.

CDHP Plan Year 2021Welcome PEBP ParticipantWelcome PEBP ParticipantWelcome to the State of Nevada Public Employees’ Benefits Program (PEBP). PEBP offers medical,dental, life insurance, long-term disability, flexible spending accounts, and other voluntary insurancebenefits for eligible state and local government employees, retirees, and their eligible dependents.As a PEBP participant, you may access whichever benefit plan offered in your geographical area thatbest meets your needs, subject to specific eligibility and Plan requirements. These plans include theConsumer Driven Health Plan (CDHP) with a Health Savings Account (HSA) or a Health ReimbursementArrangement (HRA), the Premier Plan, and the Health Plan of Nevada HMO Plan. You are alsoencouraged to research plan provider access and quality of care in your service area.All PEBP participants choosing the Consumer Driven Health Plan should examine this document, thePEBP Self-Funded PPO Dental Plan Master Plan Document (MPD) which includes a Summary ofBenefits for Life and Long-Term Disability (LTD) insurance, the Health and Welfare Wrap PlanDocument, the Section 125 Document, and the PEBP Enrollment and Eligibility Master PlanDocument. These documents are available at www.pebp.state.nv.us.Master Plan Documents are a comprehensive description of the benefits available to you. Relevantstatutes and regulations are noted in the Health and Welfare Plan Document for reference. Inaddition, helpful material is available from PEBP or any PEBP vendor listed in the Participant ContactGuide.PEBP encourages you to stay informed of the most up to date information regarding your health carebenefits. It is your responsibility to know and follow the requirements as described in PEBP’s MasterPlan Documents.Sincerely,Public Employees’ Benefits Program2

CDHP Plan Year 2021IntroductionIntroductionThis Master Plan Document describes the Consumer Driven Health Plan (also referred to as the CDHP).This Plan is available to eligible employees, retirees, and their eligible dependents participating in thePublic Employees’ Benefits Program (PEBP).The CDHP is a self-funded plan administered by PEBP and governed by the State of Nevada. Thebenefits offered with the CDHP include medically necessary behavioral health, medical, prescriptiondrug, vision, and dental coverage. Additional benefits include long-term disability and basic lifeinsurance for active employees and basic life insurance for eligible retirees. The CDHP provides aHealth Savings Account (HSA) for eligible employees and a Health Reimbursement Arrangement (HRA)for eligible retirees and active employees who are ineligible for the HSA. The medical, prescriptiondrug and vision benefits are described in this document. An independent third-party ClaimsAdministrator pays the claims for the medical, dental and vision benefits. An independent pharmacybenefit manager pays the claims for prescription drug benefits.This document is intended to comply with the Nevada Revised Statutes (NRS) Chapter 287, and theNevada Administrative Code (NAC) 287 as amended and certain provisions of NRS 695G and NRS689B. The Plan Sponsor certifies that this Article incorporates the provisions set forth in 45 CFRSection 164.504(f)(2)(ii) and the Plan Sponsor agrees to such provisions in accordance with 45 CFRSection 164.504(f)(2)(ii).The Plan described in this document is effective July 1, 2020, and unless stated differently, replacesall other CDHP medical and prescription drug benefit plan documents/summary plan descriptionspreviously provided to you.This document will help you understand and use the benefits provided by this Plan. You should reviewit and show it to members of your family who are or will be covered by the Plan. It will give you anunderstanding of the coverage provided, the procedures to follow in submitting claims, and yourresponsibilities to provide necessary information to the Plan. Be sure to read the Benefit Limitationsand Explanations, and Exclusions and Key Terms and Definitions sections. Remember, not everyexpense you incur for health care is covered by this Plan.All provisions of this document contain important information. If you have any questions about yourcoverage or your obligations under the terms of the Plan, please contact PEBP at the number listed inthe Participant Contact Guide section. The Participant Contact Guide provides you with contactinformation for the various components of PEBP.PEBP intends to maintain this Plan indefinitely, but reserves the right to terminate, suspend,discontinue, or amend the Plan at any time and for any reason. As the Plan is amended from time totime, you will be sent information explaining the changes. If those later notices describe a benefit orprocedure that is different from what is described here, you should rely on the later information. Besure to keep this document, along with notices of any Plan changes, in a safe and convenient placewhere you and your fami

PEBP CONSUMER DRIVEN HEALTH PLAN MASTER PLAN DOCUMENT PLAN YEAR 2021 (EFFECTIVE JULY 1, 2020 - JUNE 30, 2021) Public Employees' enefits Program 901 S. Stewart Street, Suite 1001