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Health Maintenance Organization (HMO) Plan Options



Plan Year 2015 HMO Medical Plan Comparison

Benefit Category Health Plan of Nevada
Southern HMO
Hometown Health HMO Plan
Northern HMO
Out-of-Pocket Maximum $6,800 per person, per calendar year $6,200 per person/$12,400 family
(two or more per calendar year)
Hospital Inpatient $300 copayment per admission $500 copayment per admission
Outpatient same-day surgery $50 copayment per admission $350 copayment per admission
Primary Care Visit $15 copayment $25 copayment
Specialist Visit $25 copayment $45 copayment
Urgent Care Visit $30 copayment $50 copayment
Emergency Room Visit $150 copayment $300 copayment
General Laboratory Services No charge No charge for outpatient or hospital
Chiropractic Services $15 copayment per visit $45 copayment per visit, $1,000 plan year max
Wellness/Prevention No charge No charge
Vision Screening Exam $10 copayment every 12 months $15 copayment every 12 months
Hardware (frames, lenses and contacts) $10 copayment for lenses & frames ($100 allowance) contacts in lieu of glasses $115 allowance. Lenses: 20% discount on glasses; Contacts: 15% discount off the contact lens exam (fitting and evaluation) when using contracted providers.

HMO Pharmacy Plan Comparison

Retail Benefit Category Health Plan of Nevada Hometown Health HMO Plan
30-Day Retail Supply 30-Day Retail Supply
Preferred Generic (Tier 1) $7 copayment $7 copayment
Preferred Brand (Teri 2) $35 copayment $40 copayment
Non-Formulary (Tier 3) $55 copayment Greater of $75 copayment or 40% coinsurance per script
Specialty Drugs Applicable retail copayment applies 30% coinsurance
Mail Order Benefit Category 90-Day Mail Order Supply 90-Day Mail Order Supply
Preferred Generic (Tier 1) $14 copayment $14 copayment
Preferred Brand (Teri 2) $70 copayment $80 copayment
Non-Formulary (Tier 3) Not available through mail order Greater of $150 copayment per script or 40%
Specialty Drugs Applicable retail copayment applies Not available through mail order

Visit Health Plan of Nevada to view:

 Plan benefits, Evidence of Coverage Certificate, Prescription Drug Formulary, and provider directory.



Visit Hometown Health Plan to view:

Prescription Drug Formulary, Evidence of Coverage,
and Summary of Benefits. You may also view your claim status and history, find providers and more.


 

 

 

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Updated April 18, 2014

 


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