Health Plan of Nevada/UHC Plans

	HMO		POS
	IN-NETWORK	TIER I NETWORK	TIER II NETWORK	TIER III OUT-OF-NETWORK
CALENDAR YEAR DEDUCTIBLE
Individual	None	None	$250	$500
Family	None	None	$500	$1,000
CALENDAR YEAR OUT OF POCKET MAXIMUM (INCLUDES DEDUCIBLE)
Individual	$6,850	$3,500	$6,250	$12,500
Family	$13,700	$7,000	$12,500	$25,000
COINSURANCE	YOU PAY	YOU PAY	YOU PAY	YOU PAY
Preventive Care	$0	$0	$0	50%
Virtual Visits	$0	$0	$0	$0
Primary Care Physician	$30 copay	$10 copay	$25 copay	50%*
Specialist	$60 copay	$30 copay	$45 copay	50%*
Urgent Care	$35 copay	$30 copay	$30 copay*	$30 copay
Emergency Room	$1,000 copay	$150 copay	$150 copay	$150 copay
Hospital Services - Inpatient	$2,000/day up to $6,000 admit	$400 copay	Ded + 20%	50%*
Hospital Services - Outpatient	$1,000 copay	$250 copay	Ded + 20%	50%*
Labs/X-Ray	Lab: $10 copay / X-ray: $20 copay	Lab: $10 copay / X-ray: $25 copay	Lab: $25 copay / X-ray: $40 copay	50%*
PHARMACY
RETAIL RX (UP TO 30-DAY SUPPLY)
Generic	$25 copay	$25 copay	$25 copay	$25 copay
Preferred	$50 copay	$50 copay	$50 copay	$50 copay
Non-Preferred	$75 copay	$75 copay	$75 copay	$75 copay
MAIL ORDER RX (UP TO 90-DAY SUPPLY)
Generic	$62.50 copay	$62.50 copay	$62.50 copay	$62.50 copay
Preferred	$125 copay	$125 copay	$125 copay	$125 copay
Non-Preferred	$187.50 copay	$187.50 copay	$187.50 copay	$187.50 copay

*After deductible