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NEVADA 2017 EHB BENCHMARK PLANSUMMARY INFORMATIONPlan TypeSmall Group MarketIssuer NameHealth Plan of Nevada, Inc.Product NameHMOPlan NameHPN Solutions HMO Platinum 15/0/90%Supplemented Categories(Supplementary Plan Type)NoneNevada—1

BENEFITS AND LIMITSABenefitBEHBPrimary Care Visit to Treat an Injury or IllnessSpecialist VisitOther Practitioner Office Visit (Nurse, PhysicianAssistant)YesYesYesCDEIs theQuantitative LimitBenefitLimit dNoFLimit UnitOutpatient Facility Fee (e.g., Ambulatory SurgeryCenter)Outpatient Surgery Physician/Surgical ServicesHospice ServicesYesCoveredNoYesYesCoveredCoveredNoYes5Days per EpisodeRoutine Dental Services (Adult)Infertility TreatmentNoYesNot Covered NoCoveredYes6Procedure(s) perLifetimeLong-Term/Custodial Nursing Home CarePrivate-Duty NursingNoYesNot Covered NoCoveredNoRoutine Eye Exam (Adult)NoNot Covered NoUrgent Care Centers or FacilitiesHome Health Care ServicesYesYesCoveredCoveredNoNoEmergency Room ServicesEmergency Transportation/AmbulanceInpatient Hospital Services (e.g., Hospital Stay)Inpatient Physician and Surgical ServicesBariatric CoveredNoNoNoNoYesCosmetic SurgerySkilled Nursing FacilityPrenatal and Postnatal CareNoYesYesNot Covered titioner" is defined as any person(s) qualified andlicensed to practice the healing arts when they areacting within the scope of their license.Limits apply to respite services ("combined maximumbenefit of five (5) Inpatient days or five (5) Outpatientvisits per Member per ninety (90) days of HomeHospice Care") and to bereavement services("maximum benefit of five (5) group therapy sessions").Advanced reproductive techniques such as embryotransplants, in vitro fertilization, GIFT and ZIFTprocedures."Covered services include office visit evaluation andlimited:1. Laboratory studies;2. Diagnostic procedures; and3. Artificial insemination services, up to six (6) cyclesper Member per lifetime. "Covered when provided by "a Hospital, AmbulatorySurgical Facility, Skilled Nursing Facility or Hospice CareFacility", subject to the benefit limitation for suchfacility services.Coverage is provided for vision exams only whenrequired to diagnose an Illness or Injury.Unlimited benefit except for One (1) medical socialservice consultation per course of treatment; One (1)nutrition consultation by a certified registered dietitian;and health aide services are furnished only whenreceiving nursing services or therapy.1Procedure(s) perLifetime100Day(s) per YearAll other weight reduction procedures are excluded.Covered Services include Prior Authorized MedicallyNecessary Gastric Restrictive Surgical Services forextreme obesity under the following circumstances:BMI of greater than 40kg/m2; or BMI greater than35kg/m2 with significant comorbidities; and providedocumented evidence that dietary attempts at weightcontrol are ineffective; and at least 18 years old.Nevada—2

ABenefitBEHBDelivery and All Inpatient Services for MaternityCareMental/Behavioral Health Outpatient ServicesYesCDEIs theQuantitative LimitBenefitLimit onQuantityCovered?Service?CoveredNoFLimit UnitYesCoveredNoMental/Behavioral Health Inpatient ServicesYesCoveredNoSubstance Abuse Disorder Outpatient ServicesYesCoveredNoSubstance Abuse Disorder Inpatient ServicesYesCoveredNoGeneric DrugsPreferred Brand DrugsNon-Preferred Brand DrugsSpecialty DrugsOutpatient Rehabilitation dCoveredNoNoNoNoYes120Visit(s) per YearHabilitation ServicesYesCoveredYes120Visit(s) per YearChiropractic CareDurable Medical EquipmentYesYesCoveredCoveredYesYes201Visit(s) per YearItem(s) per 3 YearsHearing AidsYesCoveredYes1Item(s) per 3 YearsImaging (CT/PET Scans, MRIs)Preventive Care/Screening/ImmunizationRoutine Foot CareAcupunctureWeight Loss ProgramsYesYesNoNoNoCoveredNoCoveredNoNot Covered NoNot Covered NoNot Covered NoGExclusionsTherapy is not covered for Marital or family problems;Social, occupational, or religious maladjustment;Behavior disorders; Impulse control disorders; Learningdisabilities; Mental retardation; Personality disorder;also excludes counseling and other forms of cognitiveand behavioral therapy in connection with thetreatment of Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD).Therapy is not covered for Marital or family problems;Social, occupational, or religious maladjustment;Behavior disorders; Impulse control disorders; Learningdisabilities; Mental retardation; Personality disorder;also excludes counseling and other forms of cognitiveand behavioral therapy in connection with thetreatment of Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD).Excludes maintenance care for habilitative services:"When the Member reaches his maximum level ofimprovement or does not demonstrate continuedprogress under a treatment plan, a service that waspreviously habilitative is no longer habilitative."HExplanationsAll inpatient and non-routine Outpatient nonemergency Mental Health, Severe Mental Illness orSubstance Abuse require Prior Authorization.All inpatient non-emergency Mental Health, SevereMental Illness or Substance Abuse require PriorAuthorization.All non-routine Outpatient Substance Abuse requirePrior Authorization.All inpatient Substance Abuse require PriorAuthorization.All Inpatient and Outpatient Short Term Rehabilitationand Habilitative Services are subject to a combinedmaximum benefit of one hundred twenty (120)days/visits per Member per Calendar Year.All Inpatient and Outpatient Short Term Rehabilitationand Habilitative Services are subject to a combinedmaximum benefit of one hundred twenty (120)days/visits per Member per Calendar Year.Purchases are limited to a single purchase of a type ofDME, including repair and replacement, every three (3)years.Bone anchored hearing aids are excluded except when Purchases are limited to a single purchase of a type ofeither of the following applies: For Member’s withHearing Aid, including repair and replacement, oncecraniofacial anomalies whose abnormal or absent ear every three (3) years.canals preclude the use of a wearable hearing aid; orFor Member’s with hearing loss of sufficient severitythat it would not be adequately remedied by awearable hearing aid.Nevada—3

ABenefitBEHBRoutine Eye Exam for ChildrenEye Glasses for ChildrenYesYesCDEFIs theQuantitative LimitLimit UnitBenefitLimit onQuantityCovered?Service?CoveredYes1Exam(s) per YearCoveredYes1Item(s) per YearDental Check-Up for ChildrenRehabilitative Speech TherapyYesYesCoveredCoveredYesYes1120Visit(s) per 6 MonthsVisit(s) per YearRehabilitative Occupational and RehabilitativePhysical TherapyYesCoveredYes120Visit(s) per YearWell Baby Visits and CareLaboratory Outpatient and Professional ServicesX-rays and Diagnostic ImagingBasic Dental Care - ChildOrthodontia - veredNoNoNoYesNo1Visit(s) per 6 MonthsMajor Dental Care - ChildBasic Dental Care - AdultOrthodontia - AdultMajor Dental Care – AdultAbortion for Which Public Funding is ProhibitedTransplantAccidental DentalYesNoNoNoNoYesYesCoveredNoNot Covered NoNot Covered NoNot Covered NoCoveredNoCoveredNoCoveredNoDialysisAllergy TestingChemotherapyRadiationDiabetes EducationProsthetic redCoveredCoveredNoNoNoNoNoYes1Item(s) per 3 YearsInfusion TherapyYesTreatment for Temporomandibular Joint Disorders YesNutritional CounselingYesCoveredCoveredCoveredNoNoYes1Visit(s) per EpisodeReconstructive SurgeryCoveredNoYesGExclusionsHExplanationsThe following prescription corrective lenses or frames Covers one (1) pair of lenses once every calendar earare excluded: coated lenses, cosmetic contact lenses, when a prescription change is determined Medicallyno-line bifocal or trifocal lenses, oversize lenses, plastic Necessary; One (1) pair of frames.multi-focal lenses, tinted or photochromic lenses, twopairs of lenses or frames in lieu of bifocal lenses andframes, and all prescription sunglasses.All Inpatient and Outpatient Short Term Rehabilitationand Habilitative Services are subject to a combinedmaximum benefit of one hundred twenty (120)days/visits per Member per Calendar Year.All Inpatient and Outpatient Short Term Rehabilitationand Habilitative Services are subject to a combinedmaximum benefit of one hundred twenty (120)days/visits per Member per Calendar Year.Coverage provided for Medically Necessary Servicesonly."Elective abortions" are not covered.Excludes "injuries caused by chewing."Covered when treatment starts within the first ten (10)days after the Injury and ends within sixty (60) days.Purchases are limited to a single purchase of a type ofProsthetic Device, including repair and replacement,every three (3) years.Covered if medically necessary.Only covered in relation to diabetes management ORfor an individual receiving home service (only 1nutrition consultation covered for individual receivinghome health services).Coverage limited to Mastectomy ReconstructiveSurgical Services.Nevada—4

PRESCRIPTION DRUG EHB-BENCHMARK PLAN BENEFITS BY CATEGORY AND CLASSAnalgesicsCATEGORYNonsteroidal Anti-inflammatory DrugsCLASSAnalgesicsOpioid Analgesics, Long-actingAnalgesicsOpioid Analgesics, Short-actingAnestheticsLocal AnestheticsAnti-Addiction/ Substance Abuse Treatment AgentsAnti-Addiction/ Substance Abuse Treatment AgentsAnti-Addiction/ Substance Abuse Treatment AgentsAnti-Addiction/ Substance Abuse Treatment AgentsAlcohol Deterrents/Anti-cravingOpioid Dependence TreatmentsOpioid Reversal AgentsSmoking Cessation ntibacterials, OtherAntibacterialsBeta-lactam, CephalosporinsAntibacterialsBeta-lactam, OtherAntibacterialsBeta-lactam, etracyclinesAnticonvulsantsAnticonvulsants, OtherAnticonvulsantsCalcium Channel Modifying AgentsAnticonvulsantsGamma-aminobutyric Acid (GABA) Augmenting AgentsAnticonvulsantsAnticonvulsantsGlutamate Reducing AgentsSodium Channel AgentsAntidementia AgentsAntidementia Agents, OtherAntidementia AgentsCholinesterase InhibitorsAntidementia AgentsN-methyl-D-aspartate (NMDA) Receptor AntagonistAntidepressantsAntidepressants, OtherAntidepressantsMonoamine Oxidase s (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine s, OtherAntiemeticsEmetogenic Therapy AdjunctsAntifungalsNo USP ClassAntigout AgentsNo USP ClassAnti-inflammatory AgentsGlucocorticoidsAnti-inflammatory AgentsNonsteroidal Anti-inflammatory DrugsAntimigraine AgentsErgot AlkaloidsSUBMISSION 02Nevada—5

Antimigraine AgentsCATEGORYProphylacticCLASSAntimigraine AgentsSerotonin (5-HT) 1b/1d Receptor AgonistsAntimyasthenic cobacterials, icsAlkylating ntiangiogenic tics, OtherAntineoplasticsAromatase Inhibitors, 3rd GenerationAntineoplasticsEnzyme InhibitorsAntineoplasticsMolecular Target InhibitorsAntineoplasticsMonoclonal icsPediculicides/ScabicidesAntiparkinson AgentsAnticholinergicsAntiparkinson AgentsAntiparkinson AgentsAntiparkinson Agents, OtherDopamine AgonistsAntiparkinson AgentsDopamine Precursors/ L-Amino Acid Decarboxylase InhibitorsAntiparkinson AgentsMonoamine Oxidase B (MAO-B) InhibitorsAntipsychotics1st Generation/TypicalAntipsychotics2nd ntAntispasticity AgentsNo USP ClassAntiviralsAnti-cytomegalovirus (CMV) AgentsAntiviralsAnti-hepatitis B (HBV) AgentsAntiviralsAnti-hepatitis C (HCV) AgentsAntiviralsAntiherpetic AgentsAntiviralsAnti-HIV Agents, Integrase Inhibitors (INSTI)AntiviralsAnti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)AntiviralsAnti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)AntiviralsAnti-HIV Agents, OtherAntiviralsAnti-HIV Agents, Protease InhibitorsAntiviralsAnti-influenza AgentsSUBMISSION vada—6