Py2025 CDHP MPD

CONSUMER DRIVEN HEALTH PLAN
MASTER PLAN DOCUMENT

PLAN YEAR 2025
(EFFECTIVE JULY 1, 2024 – JUNE 30, 2025)
775-684-7000
702-486-3100
1-800-326-5496
https://pebp.nv.gov
Public Employees’ Benefits Program

3427 Goni Road, Suite 109
Carson City, Nevada 89706
Table of Contents
Table of Contents
Table of Contents................................................................................................................................................... ii
Amendment Log .................................................................................................................................................. vii
Welcome PEBP Participant .................................................................................................................................... 8
Introduction........................................................................................................................................................... 9
Suggestions for Using this Document ...................................................................................................................... 10
Accessing Other Benefit Information: ...................................................................................................................... 10
Participant Rights ................................................................................................................................................ 12

You have the right to: .............................................................................................................................................. 12
Summary of the CDHP Components..................................................................................................................... 13

Highlights of the Plan .............................................................................................................................................. 13
Deductibles .............................................................................................................................................................. 14
In-Network Individual Deductible ....................................................................................................................... 14
Out-of-Network Individual Deductible ................................................................................................................ 14
In-Network Family Deductible............................................................................................................................. 14
Out-of-Network Family Deductible ..................................................................................................................... 15
Coinsurance ............................................................................................................................................................. 15
Out-of-Pocket Maximums........................................................................................................................................ 15
In-Network Out-of-Pocket Maximums ................................................................................................................ 15
Out-of-Network Out-of-Pocket Maximum .......................................................................................................... 16
Description of In-Network and Out-of-Network .................................................................................................. 18

Provider Network ..................................................................................................................................................... 18
In-Network Provider Benefits .............................................................................................................................. 18
Out-of-Network Provider Benefits ...................................................................................................................... 19
Other Providers ........................................................................................................................................................ 19
Out-of-Network Benefit Exceptions .................................................................................................................... 19
Preferred Provider Organizations (PPO Network) ................................................................................................... 21
Service Area ......................................................................................................................................................... 21
Directories of Network Providers ........................................................................................................................ 21
Eligible Medical Expenses .................................................................................................................................... 22

A Person Whose Status Changes from Employee/Retiree to Dependent or from Dependent to Employee ............ 22
Non-Eligible Medical Expenses ............................................................................................................................ 23

PPO Network Health Care Provider Services ........................................................................................................... 23
Out-of-Country Medical, Prescription and Vision Purchases ................................................................................... 24
Health Savings Accounts (HSA) ............................................................................................................................ 26
Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

ii
Table of Contents
Active Employees Only............................................................................................................................................. 26

Health Savings Account Owner Identity Verification ............................................................................................... 27
HSA Contributions for Eligible Active Employees ..................................................................................................... 28
Calendar Year 2024 HSA Contribution Limits .......................................................................................................... 28
Calendar Year 2025 HSA Contribution Limits .............................................................. Error! Bookmark not defined.
Health Reimbursement Arrangement (HRA) ........................................................................................................ 29

Active Employees and Retirees ................................................................................................................................ 29
Timely Filing of HRA Claims ..................................................................................................................................... 30
HRA Contributions for Eligible Active Employees and Retirees ............................................................................ 30
One-Time HSA or HRA Funding for Active State Employees ................................................................................. 32
HSA/HRA Contributions for Eligible State Active Employees ................................................................................ 32
Utilization Management ...................................................................................................................................... 33

Delivery of Services .................................................................................................................................................. 34
Concurrent Review ................................................................................................................................................... 34
Retrospective Review............................................................................................................................................... 34
Case Management .................................................................................................................................................. 34
Precertification (Prior Authorization) Process ......................................................................................................... 35
Services Requiring Precertification (Prior Authorization) ................................................................................... 35
Services Not Requiring Precertification (Prior Authorization)............................................................................. 37
How to Request Precertification (Prior Authorization) ....................................................................................... 38
Second Opinion ........................................................................................................................................................ 39
2nd.MD ................................................................................................................................................................. 40
Hospital Admission .................................................................................................................................................. 40
Emergency and Urgent Hospital Admission ........................................................................................................ 40
Confinement in an Out-of-Network Hospital Following an Emergency Admission ............................................ 41
Other Exceptions...................................................................................................................................................... 41
Elective Knee and Hip Joint Replacement – Nevada Exclusive Hospitals and Outpatient Surgery Centers ............. 41
Inpatient or Outpatient Surgery .............................................................................................................................. 42
Outpatient Infusion Services .................................................................................................................................... 42
Air Ambulance Services............................................................................................................................................ 42
Air/Flight Schedule Inter-Facility Transfer........................................................................................................... 42
Emergency Air Ambulance .................................................................................................................................. 43
Gender Dysphoria .................................................................................................................................................... 43
Health Care Services and Supplies Review ............................................................................................................... 43
Failure to Follow Required UM Procedures ............................................................................................................. 44
Schedule of Benefits ............................................................................................................................................ 45

iii
Table of Contents
Acupuncture and Acupressure ................................................................................................................................. 46

Allergy Services ........................................................................................................................................................ 46
Ambulance ............................................................................................................................................................... 46
Autism Spectrum Disorders Services ........................................................................................................................ 48
Bariatric/Weight Loss Surgery ................................................................................................................................. 49
Behavioral Health Services ...................................................................................................................................... 50
Blood Services for Surgery ....................................................................................................................................... 51
Chemotherapy ......................................................................................................................................................... 51
Chiropractic Services ................................................................................................................................................ 52
Clinical Trials ............................................................................................................................................................ 52
Corrective Appliances .............................................................................................................................................. 52
Diabetes Care Management Disease Program (DCM) (Enhanced Benefits) ........................................................... 53
Diabetes Education Services ............................................................................................................................... 55
Dialysis ..................................................................................................................................................................... 56
Durable Medical Equipment (DME) ......................................................................................................................... 56
No Surprises Act ....................................................................................................................................................... 57
Emergency Services ............................................................................................................................................. 57
Post Stabilization Services ................................................................................................................................... 58
Non-Emergency Items or Services from a Non-PPO Provider at a PPO Facility .................................................. 59
Air Ambulance Services ....................................................................................................................................... 60
Payments to non-PPO Providers and Facilities ................................................................................................... 60
External Review ................................................................................................................................................... 60
Continuity of Coverage ........................................................................................................................................ 60
Incorrect PPO Provider Information .................................................................................................................... 61
Enteral Formula and Special Food Product .............................................................................................................. 61
Family Planning, Fertility, Infertility, Sexual Dysfunction Services and Male Contraception ................................... 62
Gender Dysphoria .................................................................................................................................................... 63
Genetic Counseling/Testing ..................................................................................................................................... 63
Hearing Aids ............................................................................................................................................................ 64
Hinge Health ............................................................................................................................................................ 65
Home Health Care and Home Infusion Services ...................................................................................................... 65
Hospice .................................................................................................................................................................... 66
Hospital Services (Inpatient) .................................................................................................................................... 66
Laboratory Outpatient Services ............................................................................................................................... 68
Mastectomy and Reconstructive Services and Breast Reconstruction after Mastectomy ...................................... 69
Maternity and Newborn Services ............................................................................................................................ 69
Nondurable Supplies ................................................................................................................................................ 70
Obesity Care Disease Management Program (Enhanced Benefits) ......................................................................... 71

iv
Table of Contents
Oral Surgery, Dental Services, and Temporomandibular Joint Disorder.................................................................. 74

Outpatient Surgery Facility ...................................................................................................................................... 75
Physician and Other Health Care Practitioner Services ........................................................................................... 75
Preventive Care/Wellness Benefits .......................................................................................................................... 76
Radiation Therapy ................................................................................................................................................... 80
Real Appeal.............................................................................................................................................................. 81
Rehabilitation Services (Cardiac, Physical, Occupational, and Speech Therapy) ..................................................... 81
Second Physician Opinion ........................................................................................................................................ 82
2nd.MD (Second Opinion Service) ........................................................................................................................... 83
Telemedicine ............................................................................................................................................................ 83
Telehealth (other telemedicine providers) ............................................................................................................... 83
Skilled Nursing Facility (SNF) and Subacute Care Facility ........................................................................................ 83
Transplant Services (Organ and Tissue) ................................................................................................................... 84
Travel Expenses ....................................................................................................................................................... 85
Vision Screening Exam (Preventive)......................................................................................................................... 88
Schedule of Prescription Drug Benefits ................................................................................................................ 89

Prescription Drug Benefits ....................................................................................................................................... 89
48B7Preventive Drug Benefit Program ....................................................................................................................... 91
Specialty Prescription Drugs ................................................................................................................................ 91
Preferred Retail Pharmacy Network ................................................................................................................... 92
51B0Smart90 Retail and Home Delivery Program ...................................................................................................... 92
52B1............................................................................................................................................................................. 93
53B2SaveonSP Program .............................................................................................................................................. 93
54B3Diabetes Care Value ............................................................................................................................................ 94
Diabetic Medications and Supplies ..................................................................................................................... 94
5B4Extended Absence Benefit .................................................................................................................................. 94
56BOut-of-Country Emergency Medication Purchases ............................................................................................. 94
57B6Out-of-Network Pharmacy .................................................................................................................................. 95
58B7Other Limitations: ............................................................................................................................................... 95
Benefit Limitations and Exclusions ....................................................................................................................... 97

Expenses That Do Not Accumulate Toward Your Out-of-Pocket Maximum ............................................................ 97
Benefit Limitations................................................................................................................................................... 97
Lifetime Maximum................................................................................................................................................... 97
Exclusions Under the Plan........................................................................................................................................ 98
Claims Administration ....................................................................................................................................... 111

How Benefits are Paid ........................................................................................................................................... 111
How to File a Claim ................................................................................................................................................ 111
Where to Send the Claim Form .............................................................................................................................. 112

v
Table of Contents
Appeals .............................................................................................................................................................. 113

Discretionary Authority of PEBP and Designee ...................................................................................................... 113
Claims and HRA Appeals ........................................................................................................................................ 113
Written Notice of Adverse Benefit Determination ........................................................................................... 113
Level 1 Claim Appeal ......................................................................................................................................... 114
Level 2 Claim Appeal ......................................................................................................................................... 115
External Claim Review ....................................................................................................................................... 116
Appealing a Utilization Management Determination ........................................................................................... 116
Internal UM Appeal Review .............................................................................................................................. 117
External UM Appeal Review .............................................................................................................................. 118
Experimental and/or Investigational Claim/UM External Review ......................................................................... 119
Prescription Drug Review and Appeals .................................................................................................................. 119
Clinical Coverage Review ................................................................................................................................... 120
Administrative Coverage Review ...................................................................................................................... 120
Level 1 Appeal or Urgent Appeal ....................................................................................................................... 121
Level 2 Appeal ................................................................................................................................................... 122
External Reviews ............................................................................................................................................... 122
Coordination of Benefits .................................................................................................................................... 124

Which Benefits are Subject to Coordination? ........................................................................................................ 124
Which Plan Pays First: Order of Benefit Determination Rules ............................................................................... 124
Coordination with Medicare .................................................................................................................................. 127
Coordination with Other Government Programs .................................................................................................. 128
Subrogation and Third-Party Recovery .............................................................................................................. 130
Participant Contact Guide .................................................................................................................................. 131
Key Terms and Definitions ................................................................................................................................. 134

vi
Amendment Log
Amendment Log
After this document is issued, it may be amended due to changes in the law or plan design. Any
such amendments will be listed here and specify what sections have been amended and where
the changes can be found.
1. May 10, 2024 - Amended telemedicine/Doctor on Demand section, pg 83, to

clarify listed amounts are before deductible has been met.
2. May 10, 2024 - Deleted statement “Participants enrolled in the CDHP HRA
who change plans during the Open Enrollment period to a plan without an
HRA”, on page 30 due to all plans receiving HRA money, and HRA amounts
carrying over for all active employees.

vii
Welcome
Welcome PEBP Participant

Welcome to the State of Nevada Public Employees’ Benefits Program (PEBP). PEBP offers
medical, vision, dental, and life insurance, in addition to flexible spending accounts, and other
voluntary benefits 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
that best meets your needs, subject to specific eligibility and plan requirements. These plans
include the Consumer Driven Health Plan (CDHP), Exclusive Provider Organization Plan (EPO),
Low Deductible PPO Plan, and the Health Plan of Nevada HMO Plan. You are also encouraged to
research plan provider access and quality of care in your service area.
PEBP participants choosing this Plan should examine this document, the PEBP PPO Dental Plan
and Summary of Benefits for Life Insurance Master Plan Document, the Active Employee Health
and Welfare Wrap Plan Document, the Retiree Health and Welfare Wrap Plan Document, the
Section 125 Health and Welfare Benefits Plan Document, the Health Reimbursement
Arrangement (HRA) Summary Plan Description (SPD), and the Enrollment and Eligibility Master
Plan Document. These documents are available at https://pebp.nv.gov/ or by calling PEBP.
Master Plan Documents are a comprehensive description of the benefits available to you. Helpful
statutes and regulations are noted for reference. In addition, helpful material is available from
PEBP or any PEBP vendor listed in the Participant Contact Guide.
PEBP encourages you to stay informed of the most up to date information regarding your health
care benefits. It is your responsibility to know and follow the requirements as described in PEBP’s
Master Plan Documents.
Sincerely,
Public Employees’ Benefits Program

8
Introduction
Introduction
This Master Plan Document describes the Consumer Driven Health Plan (herein after referred to
the “Plan” or “CDHP”) benefits. This Plan offers In-Network and Out-of-Network benefits and is
a self-funded plan administered by PEBP and governed by the State of Nevada. The Plan is
available to eligible employees, retirees, and their eligible dependents participating in the Public
Employees’ Benefits Program (PEBP).
The benefits offered with the CDHP include medically necessary medical, behavioral health,
prescription drug, vision, and dental coverage. Additional benefits include basic life insurance for
active employees and eligible retirees. The medical, behavioral health, prescription drug, and
vision benefits are described in this document. For information regarding the dental and life
insurance benefits, refer to the PEBP PPO Dental Plan and Summary of Benefits for Life Insurance
Master Plan Document. The CDHP provides a Health Savings Account (HSA) for eligible employees
or a Health Reimbursement Arrangement (HRA) for eligible retirees and active employees who
are ineligible for the HSA.
An independent Third-Party Claims Administrator pays the claims for the medical, dental and
vision benefits. An independent pharmacy benefit manager pays the claims for prescription drug
benefits.
The Plan and this document are intended to comply with Chapter 287 of the Nevada Revised
Statutes (NRS), Chapter 287 of the Nevada Administrative Code (NAC), and all other applicable
provisions of Nevada law. Additionally, PEBP intends to incorporate herein by reference and to
comply with all applicable provisions of the Health Insurance Portability and Accountability Act
(HIPAA).
The Plan described in this document is effective July 1, 2024, and unless stated differently,
replaces other CDHP medical and prescription drug benefit plan documents/summary plan
descriptions previously provided to you.
The provisions of this document contain important information. It will help you understand and
use the benefits provided by this Plan. You should review it and show it to members of your
family who are or will be covered by the Plan. It will give you an understanding of the coverage
provided, the procedures to follow in submitting claims, and your responsibilities to provide
necessary information to the Plan. Be sure to read the Schedule of Benefits, Benefit Limitations
and Exclusions, and Key Terms and Definitions sections. Remember, not every expense you incur
for health care is covered by this Plan.
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. Members should keep informed
of this document as the Plan is amended periodically. If those later notices describe a benefit or
procedure that is different from what is described here, you should rely on the later information.
Be sure to keep this document, along with notices of any Plan changes, in a safe and convenient
place where you and your family can find and refer to them.
Public Employees' Benefits Program CDHP Plan Year 2025
9
Introduction
Per NRS 287.0485 no officer, employee, or retiree of the State has any inherent right to benefits
provided under the PEBP.
Suggestions for Using this Document

This document provides important information about your benefits. We encourage you to pay
attention to the following:
• The Table of Contents provides you with an outline of the sections.
• The Participant Contact Guide helps you become familiar with PEBP vendors and the
services they provide.
• The Participant Rights section describes your rights and responsibilities as a
participant of this Plan.
• The Key Terms and Definitions section explains many technical, medical, and legal
terms that appear in the text.
• The Eligible Medical Expenses and Non-Eligible Medical Expenses, Summary of the
CDHP Components, Schedule of Benefits, Schedule of Prescription Drug Benefits, Key
Terms and Definitions, and Benefit Limitations and Exclusions sections describe your
benefits in more detail.
• The Preventive Care/Wellness Services section provides wellness information that can
help you proactively manage your health.
• The Utilization Management section provides information on what health care
services require prior authorization and the process to request prior authorization.
• The Claims Administration section describes how benefits are paid and how to file a
claim.
• The Appeals section describes how to request a review (appeal) if you are dissatisfied
with a claim decision.
• The Coordination of Benefits section describes situations where you have coverage
under more than one health care plan, including Medicare.
Accessing Other Benefit Information:

You will also want to access the following documents for information related to dental, life,
flexible spending accounts, enrollment and eligibility, Consolidated Omnibus Budget
Reconciliation Act (COBRA), third-party liability and subrogation, Health Insurance Portability and
Accountability Act (HIPAA) and Privacy and Security and mandatory notices. These documents
are available at https://pebp.nv.gov/.
• State of Nevada PEBP Active Employee Health and Welfare Wrap Plan Document
• State of Nevada PEBP Retiree Health and Welfare Wrap Plan Document
• CDHP Summary of Benefits and Coverage for Individual and Family
• Low Deductible PPO Plan Master Plan Document
• Low Deductible PPO Plan Summary of Benefits and Coverage for Individual and
Family
• PEBP PPO Dental Plan and Summary of Benefits for Life Insurance Master Plan
Document

10
Introduction
• Exclusive Provider Organization Plan Master Plan Document

• Exclusive Provider Organization Plan Summary of Benefits and Coverage for
Individual and Family
• Health Plan of Nevada Evidence of Coverage (EOC) and Summary of Benefits and
Coverage
• PEBP Enrollment and Eligibility Master Plan Document
• Flexible Spending Accounts (FSA) Summary Plan Description
• Section 125 Health and Welfare Benefits Plan Document
• Medicare Retiree Health Reimbursement Arrangement Summary Plan Description
• Health Reimbursement Arrangement Summary Plan Document

11
Participant Rights and Responsibilities
Participant Rights
You have the right to:
• Participate with your health care professionals in your health care decisions and have
your health care professionals give you information about your condition and your
treatment options.
• Receive the benefits for which you have coverage.
• Be treated with respect and dignity.
• Privacy of your personal health information, consistent with State and Federal laws,
and the Plan’s policies.
• Receive information about the Plan’s organization and services, the Plan’s network
of health care professionals and providers and your rights.
• Candidly discuss with your physicians and providers appropriate or medically
necessary care for your condition, regardless of cost or benefit coverage.
• Make recommendations regarding the organization’s participants’ rights and
responsibilities policies.
• Express, respectfully and professionally, any concerns you may have about PEBP or
any benefit or coverage decisions the Plan, or the Plan’s designated administrator,
makes.
• Refuse treatment for any conditions, illness, or disease without jeopardizing future
treatment and be informed by your physician(s) of the medical consequences.

12
Summary of the CDHP Components

Highlights of the Plan
The CDHP is a PEBP administered Preferred Provider Organization (PPO) High Deductible Health
Plan which provides In-Network and Out-of-Network benefits. As a member, you receive
coverage for many medically necessary services and supplies. This is an open access PPO Plan
and does not require a referral to see a specialist.
The Plan includes:

• Coverage for participants residing nationwide.
• In- and Out-of-Network benefits.
• Reimbursement for Eligible Medical Expenses described in this document (and as
determined by the Plan Administrator) for participants residing permanently, part time,
or while traveling outside of the United States. Refer to the Out-of-Country Medical,
Prescription, and Vision Purchases section.
• Coverage for eligible preventive care services at 100% when using In-Network providers.
Refer to the Preventive Care/Wellness Services section for more information.
• Health care resources and tools to assist you in making informed decisions about your
and your family’s health care services. For more information log in to your E-PEBP
member portal account at https://pebp.nv.gov/.
The CDHP is coupled with either a Health Savings Account (HSA) or a Health Reimbursement
Arrangement (HRA).
Plan Year Deductibles and Out-of-Pocket Maximums
In-Network In-Network Out-of-Network Out-of-
Deductible Out-of-Pocket Deductible Network Out-
Maximum of-Pocket
Maximum
Individual $1,600 $4,000 $1,600 $10,600
(self-only
coverage)
Family Family: $3,200

Family: $8,000 Family: $21,200
Individual $3,200
family member:
$6,850
In-Network and Out-of-Network Deductibles and Out-of-Pocket Maximums are not
interchangeable.
The Deductibles and Out-of-Pocket Maximums accumulate separately for In-Network and
Out-of-Network provider expenses. See Family Deductible explanation below.

13
Deductibles
The Plan Year Deductibles (combined medical and prescription drug) includes two tiers:
• Individual Deductible: Applies when only one person is covered on the Plan (self-
only coverage).
• Family Deductible: Applies when two or more individuals are covered on the same
Plan (e.g., Employee plus Spouse, Employee plus Spouse and Child, etc.). The
Family Deductible may be met through a combination of Eligible Medical Expenses
from covered family members.
The Individual and Family Deductibles start July 1st (the first day of the Plan Year) and reset the
following Plan Year on July 1st. This Plan does not include a Deductible carryover or rollover
provision.
During the Plan Year, you are responsible for paying for your eligible medical and prescription
drug expenses (except eligible Preventive Services provided In-Network), including amounts
exceeding the Plan’s reference-based pricing for hip and knee replacement, preauthorization
penalties, and other out of pocket costs.
In-Network Individual Deductible

The In-Network Individual Deductible applies when only one person is covered on the Plan. For
this Plan Year, the Deductible is $1,600. Participants are responsible for paying Out-of-Pocket for
eligible medical and prescription drug expenses that are subject to the Deductible. Once the
Individual Deductible is met, the Plan will pay its cost-share of eligible benefits. (In-Network and
Out-of-Network Deductibles are not interchangeable, meaning the Deductibles accumulate
separately for In-Network provider expenses and Out-of-Network provider expenses.) Deductible
credit is based on the date the medical or prescription drug expense is received by the Plan and
not on the date of service.
Out-of-Network Individual Deductible

The Out-of-Network Individual Deductible applies when only one person is covered on the Plan.
For this Plan Year, the Deductible for Eligible Medical Expenses received Out-of-Network is
$1,600. Participants are responsible for paying Out-of-Pocket for eligible medical (prescription
drugs are not covered Out-of-Network) expenses up to the Plan Year Deductible. Once the
Individual Deductible is met, the Plan will pay its cost-share of eligible benefits. (In-Network and
Out-of-Network Deductibles are not interchangeable, meaning the Deductibles accumulate
separately for In-Network provider expenses and Out-of-Network provider expenses.)
Deductible credit is based on the date the medical or prescription drug expense is received by
the Plan and not on the date of service.
In-Network Family Deductible

The In-Network Family Deductible applies when two or more individuals are covered on the same
Plan. For this Plan Year, the Family Deductible is $3,200. For a participant covered with one or
more dependents, this Plan will pay benefits for eligible In-Network medical and prescription

14
drug expenses for the entire family after the $3,200 Family Deductible is met. The $3,200 In-
Network Family Deductible may be met by any combination of Eligible Medical Expenses from
covered individuals in the family. The Family Deductible accumulates separately for In-Network
provider and Out-of-Network provider expenses. Deductible credit is based on the date the
medical or prescription drug expense is received by the Plan and not on the date of service.
Out-of-Network Family Deductible

The Out-of-Network Family Deductible applies when two or more individuals are covered on the
same Plan. For this Plan Year, the Family Deductible is $3,200 . For a participant covered with one
or more dependents, this Plan will pay benefits for eligible Out-of-Network medical and vision
(prescription drugs are not covered Out-of-Network) expenses for the entire family after the
$3,200 Family Deductible is met. The $3,200 Family Deductible may be met by any combination
of Eligible Medical Expenses from covered individuals in the family. The Family Deductible
accumulates separately for In-Network provider and Out-of-Network provider expenses.
Deductible credit is based on the date the medical or prescription drug expense is received by
the Plan and not on the date of service.
Coinsurance
Coinsurance is the percentage of costs that you and the Plan pay for Eligible Medical Expenses
after your Deductible is met. If you receive covered health care services using a health care
provider who is a participating provider of this Plan’s PPO network, you will be paying less money
out of your pocket. This Plan generally pays 80% of the In-Network provider’s contract rate and
you are responsible for paying the remaining 20%. If you use an Out-of-Network provider (a non-
participating provider, meaning the provider is not contracted with the PPO network), the Plan
benefit may be reduced to 50% of the Maximum Allowable Charge, and you are responsible for
paying the remaining 50%. Out-of-Network providers can also bill you directly for any difference
between their billed charges and the Maximum Allowable Charge allowed by this Plan, except
when prohibited by law.
Out-of-Pocket Maximums
In-Network Out-of-Pocket Maximums
The In-Network Out-of-Pocket Maximum (OOPM) is the maximum amount you will pay for In-
Network eligible medical and prescription drug expenses during the Plan Year. The Out-of-Pocket
costs you pay toward your Deductible and Coinsurance for Eligible Medical Expenses accumulate
toward your OOPM. The OOPM for:
• An Individual (covered as self-only) is $4,000

• Family coverage (participant plus one or more covered dependents) is $8,000
o The Family OOP Maximum includes a $6,850 embedded “Individual Family
Member” OOP Maximum. An Individual Family Member OOP Maximum
means one single family member will not pay more than $6,850 in the Plan
Year for Eligible Medical Expenses.

15
Once an Individual or Family satisfies the OOP Maximum, the Plan will pay 100% of eligible
medical and prescription drug expenses for the remainder of the Plan Year. The OOP Maximum
accumulates on a Plan Year basis and resets to zero at the start of a new Plan Year. The
accumulation of Eligible Medical Expenses toward the OOP Maximum is based on the date the
medical or prescription drug expense is received by the Plan and not on the date of services.
Only Eligible Medical Expenses that are subject to cost-sharing (Deductible, Copayments, and
Coinsurance) will apply to the OOPM. The OOPM does not include premiums, cost-sharing for
non-covered supplies and services, penalties for failure to get preauthorization, amounts
exceeding the Plan’s allowable charge for hip and knee replacement, expenses associated with
denied claims, ancillary charges, and amounts billed by Out-of-Network providers that are
payable and greater than this Plan’s Maximum Allowable Charge. This list is not all-inclusive and
may not include certain services and supplies that are not listed here.
For this section only, references to the OOPM, Eligible Medical Expenses, Deductible and
Coinsurance are specific to In-Network benefits.
Out-of-Network Out-of-Pocket Maximum

The Out-of-Network Out-of-Pocket Maximum (OOPM) is the maximum amount you will pay for
Eligible Medical Expenses (excluding prescription drugs) during the Plan Year. The Out-of-Pocket
costs you pay toward your Deductible and Coinsurance for Eligible Medical Expenses accumulate
toward your OOPM. The OOPM for:
• Individual (covered as self-only) is $10,600.

• Family coverage (participant plus one or more covered dependents) is $21,200.
(The Family coverage tier does not include an embedded Individual Family
Member OOP Maximum.)
Once the OOP Maximum is met, the Plan will pay 100% of Eligible Medical Expenses (excluding
Out-of-Network prescription drug expenses) for the remainder of the Plan Year. The OOP
Maximum accumulates on a Plan Year basis and resets to zero at the start of a new Plan Year.
The accumulation of Eligible Medical Expenses toward the OOPM is based on the date the
medical expense is received by the plan and not on the date of services.
The Family OOP Maximum (for Out-of-Network services only) can be met by one person or by a
combination of Out-of-Pocket Eligible Medical Expenses from covered family members.
Only Eligible Medical Expenses that are subject to cost-sharing (Deductible, Copayments, and
Coinsurance) will apply to the OOP Maximum. The OOP Maximum does not include premiums,
cost-sharing for non-covered supplies and services, penalties for failure to obtain
preauthorization, amounts exceeding the Plan’s allowable charge for hip and knee replacement,
expenses associated with denied claims, ancillary charges, and any amount that Out-of-Network
providers bill and are payable that are greater than this Plan’s Maximum Allowable Charge. This
list is not all-inclusive and may not include certain services and supplies that are not listed here.

16
References to the Out-of-Network, OOP Maximum, Eligible Medical Expenses, Deductible and
Coinsurance in this section are specific to Out-of-Network benefits.
In- and Out-of-Network Maximums are not interchangeable and cannot be combined to reach
your Plan Year OOPM.

17
Description of In-Network and Out-of-Network

Provider Network
PEBP leases a network of preferred providers (PPO) through a contract with a vendor who
maintains such a network. For more information, see the Participant Contact Guide. In-Network
providers are hospitals, physicians, medical laboratories, and other health care providers located
within a “service area” who have agreed to provide health care services and supplies at
negotiated discount fees. Network providers are not the Plan’s employees or employees of any
Plan designee.
The contracted PPO Network is responsible for credentialing providers by confirming public
information about the providers’ licenses and other credentials but does not assure the quality
of the services provided.
Before obtaining services, you should always verify the network status of a provider. A provider’s
status may change. You can verify the provider’s status by calling the third-party administrator
or on the PEBP website in the Find a Provider section. The provider listing is maintained and
updated by the contracted network.
The provider network is subject to change. It is possible that you might not be able to obtain
specific services from an In-Network provider. Or you might find that an In-Network provider may
not be accepting new patients. If a provider leaves the network or is otherwise not available, you
must choose another In-Network provider to get In-Network benefits.
Do not assume that an In-Network provider’s agreement includes all Eligible Medical Expenses.
Some In-Network providers agree to provide only certain covered expenses, but not all covered
expenses. Some In-Network providers choose to be an In-Network provider for only some
products and services. You may contact the third-party administrator for assistance in choosing
a provider or with questions about a provider’s network participation .
Pursuant to NRS 695G.164, if a member is receiving medical treatment from a provider whose
In-Network status changes during the course of treatment, the member may continue to receive
treatment with that provider at In-Network rates under certain circumstances. See a more
detailed explanation in PPO Network Health Care Provider Services section.
In-Network Provider Benefits

The Plan provides In-Network benefits when the services are provided by an In-Network provider
and generally pays at a higher amount than Out-of-Network benefits. In-Network benefits are
payable for covered Eligible Medical Expenses.
When a participant uses the services of a PPO network (In-Network) health care provider, the
participant is responsible for paying the applicable cost-share (Deductible, Copay, and/or
Coinsurance) on the discounted fees for medically necessary services or supplies, subject to the
Plan’s coverage, limitations, and exclusions.

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If you receive medically necessary services or supplies from an In-Network provider, you will pay
a lower cost than if you received those services or supplies from a health care provider who is
not in the PPO network (Out-of-Network). In-Network providers have agreed to accept the Plan’s
payment (plus any applicable cost-share you are responsible for paying) as payment in full. The
In-Network health care provider generally deals with the Plan or its designee directly for any
additional amount due.
Out-of-Network Provider Benefits

Out-of-Network Eligible Medical Expenses are subject to applicable Deductibles and a
Coinsurance rate of 50% of eligible billed charges and subject to the Plan’s Maximum Allowable
Charge, except when prohibited by law.
Out-of-Network health care providers have no agreements with the Plan and are generally free
to set their own charges for the services or supplies they provide. The Plan will pay benefits based
on the Plan’s Maximum Allowable Charge (as defined in the Key Terms and Definitions) on non-
discounted medically necessary services or supplies, subject to the Plan’s cost-share (Deductibles,
Copay, and/or Coinsurance). With exception of services subject to the No Surprises Act, Out-of-
Network health care providers may bill the participant for any balance that may be due in
addition to the amount paid by the Plan (called balance billing). Balance billing for Eligible Medical
Expenses can be avoided by using In-Network Providers.
Other Providers
If you have a medical condition that the third-party administrator or the utilization management
company believes needs special services, they may direct you to a provider identified by them. If
you require certain complex covered services for which expertise is limited, the third-party
administrator or the utilization management company may direct you to an Out-of-Network
provider. In both cases, benefits will only be paid at the In-Network benefit level (subject to the
Maximum Allowable Charge) if your covered expenses for that condition are provided by or
arranged by the other provider as chosen by third-party claims administrator or the utilization
management company.
Participants may obtain health care services from In-Network or Out-of-Network health care
providers. Because providers are added and dropped from the PPO network periodically
throughout the year, it is the participant’s responsibility to verify provider participation before
receiving services by contacting the third-party claims administrator at the telephone number or
by visiting the provider network’s website available at https://pebp.nv.gov/.
Out-of-Network Benefit Exceptions

If there is no In-Network provider within 50 miles of your home, you may be eligible to receive
benefits for certain Eligible Medical Expenses paid at the In-Network level, subject to the Plan’s
Maximum Allowable Charge (with exception of services subject to the No Surprises Act). Benefits
that fall under this category must be approved prior to receipt of the care and are subject to any
Plan Benefit Limitations and Exclusions set forth in this MPD.

19
If you are traveling outside your network and you need non-emergency medical care, you should
contact the third-party administrator at the telephone number appearing on your medical
identification card for assistance in locating the nearest In-Network provider.
Emergency Care
The Plan provides benefits for emergency care when required for stabilization and initiation of
treatment as provided by or under the direction of a health care provider. Eligible Medical
Expenses that are provided as a result of emergent care are paid at the In-Network level,
regardless of whether the provider is In-Network or Out-of-Network.
Confinement in an Out-of-Network Hospital Following an Emergency

If you are confined in an Out-of-Network hospital after you receive emergency services, the
utilization management company should be notified as soon as possible and must be notified
within two business days at the latest. The UM company may elect to transfer you to an In-
Network hospital as soon as it is medically appropriate to do so. If, after receiving required notice
and providing informed consent, you choose to stay in the Out-of-Network hospital after the UM
company determines a transfer is medically appropriate, the Plan will pay Eligible Medical
Expenses at the Out-of-Network benefit level, subject to the Plan’s Maximum Allowable Charge
if the continued stay is authorized by the UM company and determined to be a covered service.
Other Exceptions
If you receive ancillary services such as an x-ray, laboratory services, or anesthesia services from
an Out-of-Network provider while receiving services at an In-Network inpatient or outpatient
facility (such as an outpatient surgery center), the Plan will cover the Eligible Medical Expenses
at the In-Network benefit level, subject to the Plan’s Maximum Allowable Charge.
When Out-of-Network Providers May be Paid as In-Network Providers

When a participant uses the services of an Out-of-Network provider for Eligible Medical Expenses
in the circumstances defined below, charges by the Out-of-Network provider will be subject to
the Plan’s Maximum Allowable Charge (as defined in the Key Terms and Definitions section). Out-
of-Network providers may bill the participant for any balance that may be due in addition to the
amount paid by the Plan (called balance billing).
• If a participant traveling to an area serviced by an In-Network provider

experiences an urgent but not life-threatening situation and cannot access an In-
Network provider, benefits may be paid at the In-Network benefit level for use of
an Out-of-Network urgent care facility.
• In the event of a life-threatening emergency in which a participant uses an Out-
of-Network urgent care.
• For medically necessary services or supplies when such services or supplies are
not available from an In-Network provider within 50 driving miles of the
participant’s residence. This includes services provided for wellness/preventive,
or a second opinion.
• Participant travels to an area not serviced by an In-Network provider within 50
miles.

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• If a participant travels to an area serviced by an In-Network provider, the

participant must use an In-Network provider to receive benefits at the In-Network
benefit level.
• If there is a specialty not available inside the participant’s eligible PPO network,
benefits may be paid as In-Network.
Preferred Provider Organizations (PPO Network)

A preferred provider organization (PPO) network is a list of the doctors, other health care
providers, and hospitals that the Plan has a contract with to provide medical care for Plan
members. These providers are called “network providers” or “In-Network providers.”
This Plan includes a PPO network for members residing in-and outside-of Nevada. To locate an
In-Network provider visit the PEBP website at https://pebp.nv.gov/ or contact the third-party
claims administrator. Information regarding the PPO network is also available in the Participant
Contact Guide section of this document.
Service Area
A “Service Area” is a geographic area serviced by In-Network health care providers. If you and or
your covered dependent(s) live more than 50 driving miles from the nearest In-Network health
care provider whose services or supplies are determined by the Plan Administrator or its designee
as being appropriate for the condition being treated, the Plan will consider that you live outside
the service area. In that case, your claim for medically necessary services or supplies from an Out-
of-Network health care provider will be treated as if the services or supplies were provided In-
Network, subject to the Maximum Allowable Charge.
Directories of Network Providers

Participants are encouraged to confirm the In-Network participation status of a provider prior to
receiving services.
A list of PPO providers is available to you without charge by visiting your member website from
the Third-Party Administrator’s website or by calling the phone number on your ID card. The
network consists of providers, including hospitals, of varied specialties as well as general practice,
who are contracted with the Plan or an organization contracting on its behalf.
The online provider directory updates are made seven (7) days a week for Sierra HealthCare
Options (SHO) and Behavioral Healthcare Options (BHO) networks. UHC Choice Plus providers
are available in the Find Care and Cost tool available 24/7 yearly updates. The list of PPO
providers is maintained and updated by the contracted network based on information supplied
by Providers.
If you obtain and rely upon incorrect information about whether a provider is a PPO provider
from the Plan or its administrators, the Plan will apply PPO cost-sharing to your claim, even if
the provider was Non-PPO.

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Eligible Medical Expenses
Eligible Medical Expenses

You are covered for expenses you incur for most, but not all, medical services, and supplies. The
expenses for which you are covered are called Eligible Medical Expenses. Eligible medical
expenses are limited to the covered benefits specified in the Schedule of Benefits and
are:
• Determined by the Plan Administrator or its designee to be medically necessary
(unless otherwise stated in this Plan), but only to the extent that the charges are
usual and customary (U&C), provided in-network, and/or do not exceed this Plan’s
Maximum Allowable Charge (as those terms are defined in the Key Terms and
Definitions section).
• Not services or supplies that are excluded from coverage (as provided in the
Benefit Limitations and Exclusions section).
• Charges for services or supplies that do not exceed the Plan Year maximum
benefits as shown in the Schedule of Benefits.
Generally, the Plan will not reimburse you for all Eligible Medical Expenses. Usually, you will have
to pay some portion of costs, known as cost-sharing such as Coinsurance toward the amounts
you incur for Eligible Medical Expenses. However, once you have incurred the Plan Year Out-of-
Pocket Maximum cost for Eligible Medical Expenses, no further Coinsurance will apply for the
balance of the Plan Year. There are also maximum benefits applicable to each participant.
The above is not all-inclusive. For more information regarding eligible medical expenses, see the
Schedule of Benefits, Key Terms and Definitions, Benefit Limitations and Exclusions sections.
A Person Whose Status Changes from Employee/Retiree to Dependent or from

Dependent to Employee
A person who is continuously covered on this Plan before, during, and after a change in status,
will be given credit for portions of the medical, prescription drug and dental Deductibles
previously met in the same Plan Year, including the benefit maximum accumulators (e.g., medical
Out-of-Pocket Maximums, dental frequency maximums and annual benefit maximum) will
continue without interruption.

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Non-Eligible Medical Expenses

Non-eligible medical expenses are expenses that are excluded from the Plan and do not
accumulate towards your Deductible and Out-of-Pocket Maximum.
This Plan does not pay benefits equal to all the medical expenses you may incur. You are
responsible for paying the full cost of all expenses that are not Eligible Medical Expenses,
including expenses that are:
• Not determined to be medically necessary (unless otherwise stated in this Plan).

• Determined to exceed this Plan’s Maximum Allowable Charge.
• Expenses for medical services or supplies that are not covered by the Plan,
including, but not limited to, expenses that exceed the PPO provider contract rate,
services listed in the Exclusions section of this document and dental expenses.
• Benefits exceeding those services or supplies subject to limited overall maximums
for each covered individual for certain Eligible Medical Expenses.
• Additional amounts you are required to pay because of a penalty for failure to
comply with the Plan’s utilization management requirements described in the
Utilization Management section of this document. If you fail to follow certain
requirements of the Plan’s utilization management program, the Plan may pay a
smaller percentage of the cost of those services, and you may have to pay a
greater percentage of those costs. The additional amount you may have to pay is
in addition to your Deductibles or Out-of-Pocket Maximums described in the
tables.
• Preventive Care/Wellness Services that are paid by the Plan at 100% do not
accumulate towards the Out-of-Pocket Maximum.
This list is not all-inclusive and may include certain services and supplies that are not listed above.
Non-Eligible Medical Expenses do not accumulate toward the Plan Year Deductible or Out-of-
Pocket Maximum as determined by the Plan Administrator for your specific coverage tier. You
are responsible for paying these expenses out of your own pocket.
For more information regarding Non-Eligible Medical Expenses, see the Benefit Limitations and
Exclusions section.
PPO Network Health Care Provider Services

If you receive medical services or supplies from an In-Network PPO provider, you will be
responsible for paying less money out-of-pocket. Health care providers who are participating
providers of the PPO network have agreed to accept the PPO network negotiated amounts in
place of their standard charges for covered services. You are responsible for any applicable Plan
Deductible and Coinsurance requirements as outlined in this document and are described in
more detail in the Schedule of Benefits.

23
With exception of services subject to the No Surprises Act, Out-of-Network providers may bill the
participant their standard charges and any balance that may be due after the Plan payment. It is
the participant’s responsibility to verify the In-Network status of a chosen provider.
NOTE: In accordance with NRS 695G.164, if you are seeing a provider that is In-Network and that
provider leaves the network, and you are actively undergoing a medically necessary course of
treatment, and you and your provider agree that a disruption to your current care may not be in
your best interest or if continuity of care is not possible immediately with another In-Network
provider, PEBP will pay that provider at the same level they were being paid while contracted
with PEBP’s PPO network, if the provider agrees. If the provider agrees to these terms, coverage
may continue until:
• The 120th day after the date the contract is terminated; or

• If the medical condition is pregnancy, the 90th day after:
o The date of delivery; or
o If the pregnancy does not end in delivery, the date of the end of the pregnancy.
Out-of-Country Medical, Prescription and Vision Purchases

This Plan provides you with coverage worldwide. Whether you reside in the United States and
travel to a foreign country, or if you reside outside of the United States permanently or on a part-
time basis, and require medical, prescription drug, or vision care services, you may be eligible for
reimbursement of the cost.
Please contact this Plan’s third-party claims administrator and pharmacy benefit manager before
traveling or moving to another country to discuss any criteria that may apply to a medical,
prescription drug, or vision service reimbursement request.
Typically, foreign countries do not accept payment directly from the Plan. You may be required
to pay for medical and vision care services and submit your receipts to this Plan’s third-party
claims administrator for possible reimbursement. Medical and vision services received outside of
the United States are subject to Plan provisions, coverage, limitations, exclusions, clinical review
if necessary, and determination of medical necessity. The review may include application of
pertinent Food and Drug Administration (FDA) regulations Out-of-country medication purchases
are only eligible for reimbursement while traveling outside of the United States.
The third-party claims administrator may require a written notice from you or your designated
representative explaining why you received the medical services from an out of country provider
and why you were unable to travel to the United States for these services. This provision applies
to elective and emergency services.
Prior to submitting receipts from a foreign country to this Plan’s third-party claims administrator,
you must complete the following:
• Proof of payment from you to the provider of service (typically your credit card invoice).
• Itemized bill to include complete description of the services rendered and admitting
diagnosis(es).
24
• Itemized bill must be translated to English.

• Reimbursement request converted to United States dollars.
• Foreign purchases of medical care and services are subject to Plan limitations such
as:
o Benefit coverage
o Coinsurance and deductibles
o Frequency maximums
o Annual benefit maximums
o Medical necessity
o FDA approval
o the Plan’s Maximum Allowable Charge
The Plan administrator and the third-party claims administrator reserve the right to request
additional information. If the provider will accept payment directly from the claim’s
administrator, you must also provide the following:
• Assignment of benefits signed by you or an individual with the authority to sign
on your behalf such as a legal guardian or Power of Attorney (POA).
Once payment is made to you or to the out-of-country provider, the Plan administrator and its
vendors are released from any further liability for the out-of-country claim. The Plan
administrator has the exclusive authority to determine the eligibility of all medical services
rendered by an out-of-country provider. The Plan administrator may or may not authorize
payment to you or to the out-of-country provider if all requirements of these provisions are not
satisfied.
This Plan may provide certain benefits for travel assistance back to the United States.
This Plan may provide benefits for the purposes of emergency medical transportation only. For
more information, contact this Plan’s third-party claims administrator listed in the Participant
Contact Guide.

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Health Savings Accounts
Health Savings Accounts (HSA)

Active Employees Only
The Consumer Driven Health Plan (CDHP) is an IRS qualified High Deductible Health Plan. This
means the CDHP complies with federal requirements regarding Deductibles, Out-of-Pocket
Maximums, and certain other features. As a qualified High Deductible Health Plan, the CDHP is
coupled with a Health Savings Account (HSA). A Health Savings Account is a tax-exempt account
that you can use to pay or reimburse yourself for certain medical expenses you incur. For
further information on Health Savings Accounts, see IRS Publication 969.
HSAs are employee-owned accounts, meaning the funds in the HSA remain with the employee
and carry over from one year to the next (i.e., will not be forfeited). Contributions to the HSA
grow tax free and are portable. When an employee retires or terminates employment, the
employee retains the funds in the HSA. The employee can continue to use the funds in the HSA
for health care and other qualified medical expenses after employment ends.
There are limits on the amount an eligible individual can contribute to an HSA based on the
employee’s coverage tier. For example, “self-only” or “Family” coverage:
• Self-only coverage means an eligible individual (employee).
• Family coverage means an eligible employee covering at least one dependent (whether
that dependent is an eligible individual (for example, if the dependent has Medicare) if
that other person is claimed on your tax return and not claimed as a tax dependent on
someone else’s return.
You must be an eligible individual to qualify for an HSA. Employees may not establish or
contribute to a Health Savings Account if any of the following apply:
• The employee is covered under other medical insurance coverage unless that
medical insurance coverage: (1) is also a High Deductible Health Plan as defined
by the IRS; (2) covers a specific disease state (such as cancer insurance); or (3) only
reimburses expenses after the Deductible is met.
• The employee is enrolled in Medicare.
• The employee is enrolled in Tricare.
• The employee is enrolled in Tribal coverage.
• The employee can be claimed as a dependent on someone else’s tax return unless
the employee is Married Filing Jointly.
• The employee or the employee’s spouse has a Medical Flexible Spending Account
(excludes Dependent Care or Limited Use Flexible Spending Accounts) that can
reimburse the employee’s medical expenses.
• The employee’s spouse has an HRA that can be used to pay for the medical
expenses of the employee.
• The employee is on COBRA; or
• The employee is retired.

26
If an employee loses eligibility to contribute to a Health Savings Account (HSA) for any reason,
the Plan reserves the right to cease processing employee contributions to the HSA for the
remainder of the Plan Year. If an HSA ineligible employee elects to continue coverage in the Plan
for the subsequent Plan Year, the employee will only be eligible to enroll in the Health
Reimbursement Arrangement (HRA) to receive PEBP contributions as described below. The HSA
third-party claims administrator reserves the right to verify Medicare eligibility with the Centers
for Medicare and Medicaid Services (CMS).
Employees who wish to establish or contribute to an HSA should contact the HSA third-party
claims administrator regarding eligibility requirements, consult with a tax professional or read
the provisions described in IRS Publication 969.
Current CDHP participants who are eligible for the HSA will receive PEBP contributions during the
first month of the new Plan Year. New hires receive a prorated contribution based on the
coverage effective date and the number of months remaining in the Plan Year. HSA funds may
not be used for a person who does not meet the IRS definition of dependent, including many
domestic partners, children of domestic partners and older children who cannot be claimed on
the participant’s tax return, regardless of whether the dependent is covered under this Plan. In
general, HSA funds may not be used to pay premiums. There are certain exceptions for retirees
or former employees enrolled in a Plan offered under COBRA provisions.
HSA funds may only be used to pay, or reimburse expenses incurred after the HSA is established
and can only be reimbursed if there are available HSA funds in the account.
HSA Bank, a division of Webster Bank, N.A., is the third-party claims administrator and custodian
for the HSA. PEBP does not (i) endorse HSA Bank, a division of Webster Bank, N.A. as an HSA
provider; (ii) limit an employee’s ability to move funds to other HSA providers, (iii) impose
conditions on how HSA funds are spent, (iv) make or influence investment decisions regarding
HSA funds, or (v) receive any payment or compensation in connection with an HSA. PEBP HSA
contributions and employee voluntary pre-tax payroll deductions will only be deposited to an
HSA at HSA Bank, a division of Webster Bank, N.A. Employees may choose to establish an HSA
with any HSA trustee or custodian and may transfer funds deposited into HSA Bank, a division of
Webster Bank, N.A. account to another HSA account held by another trustee or custodian.
However, PEBP will not pay any fees associated with any other HSA account including transfer
fees.
The IRS requires any person with an HSA to submit form 8889 with their annual income tax
return.
Health Savings Account Owner Identity Verification

Section 326 of the USA PATRIOT Act requires financial institutions to verify the identity of each
employee who opens a Health Savings Account (HSA). If an employee’s identity cannot be
verified, the employee will be required to provide additional documentation to establish their
identity. If additional verification is not provided within 90 days of the employee’s HSA opening
date, the HSA will be closed. Failure to comply with the identity verification requirement within
27
the stated timeframe will result in the conversion from an HSA to a Health Reimbursement
Arrangement (HRA) for the remainder of the Plan Year. The next opportunity to establish an HSA
will be during the Open Enrollment Period for the subsequent Plan Year.
HSA Contributions for Eligible Active Employees

Tier Contribution
Active Participant (Employee/Retiree) Only *$600
*HSA contribution provided to HSA eligible active employees enrolled in the CDHP on July 1,
2024. New hires with benefits effective August 1, 2024, and later receive a pro-rated contribution
based on their CDHP coverage effective date. For Plan Year 2025, dependents are not eligible for
a PEBP HSA contribution. Under no circumstances will a participant who received contributions
during the Plan Year be eligible for additional contributions due to reinstatement of coverage or
changing from the CDHP with an HSA to the CDHP with a HRA or vice versa.
Calendar Year 2024 HSA Contribution Limits

Family
Individual
(two or more HSA eligible family members)
$4,150 $8,300
Total contributions (combined employee/employer) cannot exceed the 2024 calendar year limit, as
determined by the IRS (Revenue Procedure 2023-23). To contribute the family maximum, the
employee and at least one tax dependent must be covered on the CDHP Plan. The Family maximum
applies regardless of whether two employees are married and enrolled in the CDHP and eligible for
the HSA. Employees aged 55 years and older at the end of the tax year may contribute an additional
$1,000 to the HSA.

28
Health Reimbursement Arrangement
Health Reimbursement Arrangement (HRA)

PEBP and its vendor require direct deposit for HRA reimbursements. PEBP’s HRA benefits are
subject to the provisions explained in IRS Publication 969. Also see the HRA Summary Plan
Description document on PEBP’s website.
Active Employees and Retirees

This section provides summary information only. For more detailed information regarding this
important benefit, see IRS Publication 502 or contact the HRA third-party claims administrator
listed in the Participant Contact Guide.
The CDHP with an HRA is available to active employees who are not eligible for an HSA, or who
fail to establish an HSA. An HRA is also available to eligible retirees enrolled in the CDHP.
Each Plan Year, PEBP contributions will be available for use through a CDHP HRA account
established in the employee’s or retiree’s name. Funds in the CDHP HRA account may be used,
tax-free, to pay for qualified medical expenses as defined by the IRS (see IRS Publication 502),
other than premiums, including payment of Deductibles, Coinsurance, and other Out-of-Pocket
qualifying healthcare expenses not covered by this Plan.
The CDHP’s HRA may only be used to pay or reimburse qualified Out-of-Pocket health care
expenses incurred by:
• the participant;
• the participant’s spouse; or
• participant’s dependent(s) who could be claimed on the participant’s annual tax
return.
CDHP HRA funds may not be used for a person who does not meet the IRS definition of a qualified
tax dependent, including many domestic partners, children of domestic partners, and older
children who cannot be claimed on the participant’s tax return, regardless of whether PEBP
provides coverage for the dependent.
The entire annual PEBP base contribution for Plan Year 2025 will be available for use at the
beginning of the Plan Year on or about July 1, 2024 (subject to certain limitations). Participants
who initially elect PEBP coverage after July 1, 2024, will receive a pro-rated base contribution for
the participant based upon the coverage effective date and the months remaining in the Plan
Year. Participants cannot contribute to a CDHP HRA. If the annual funds in the CDHP HRA are
exhausted, neither PEBP nor the participant will contribute any additional funds.
Participants are allowed the option annually, and at termination in the plan, to permanently opt-
out of the HRA, and thereby forfeit any unused balance.

29
Any funds remaining in the CDHP HRA at the end of the Plan Year will carryover (i.e., will not be
forfeited) and will be available for use in the following Plan Year. Unlike a Flexible Spending
Account (FSA), participants cannot be reimbursed from funds that are not yet available in the
CDHP HRA. Any reimbursement from the CDHP HRA will be the lesser of the available CDHP HRA
balance or the claim amount paid to the provider.
Retirees who transition coverage to the Via Benefits Medicare exchange will forfeit any remaining
funds in their CDHP HRA account.
Active employees who retire and who are not Medicare age (typically at age 65 years) can
maintain the balance of their CDHP HRA account at retirement if:
• They are eligible to enroll in and continue coverage under a PEBP plan; or
• Continue coverage under COBRA.
o If a participant elects COBRA coverage, the HRA account will remain in place until
COBRA coverage is terminated.
In the case of a retroactive coverage termination, any funds used from the CDHP HRA for
expenses that are incurred after the date of coverage termination will be recovered by PEBP
through the collection process.
Retirees who have a CDHP HRA balance and who transition to the Medicare Exchange will forfeit
any remaining funds in the HRA on the last day of coverage under the Plan.
The death of an active employee or retiree will cause any remaining funds in the HRA to be
forfeited on the first day following the date of death.
Timely Filing of HRA Claims

In accordance with NAC 287.610, claim requests must be submitted to the third-party claims
administrator within one year from the date of service that the claim is incurred. No plan benefits
will be paid for any claim requests submitted after this period.
When your HRA-eligible coverage ends, you will have one year from the date your coverage ends
to file a claim for reimbursement from your HRA for eligible claims incurred during your coverage
period in accordance with NAC 287.610, dependent on the date of service. CDHP HRA funds may
not be used to pay premiums.
HRA Contributions for Eligible Active Employees and Retirees

Employee/Retiree Contribution
Participant Only *$600

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*HRA contribution provided to eligible active employees and retirees enrolled in this Plan on July
1, 2024. For Plan Year 2025, dependents are not eligible for PEBP HRA contributions. New hires
effective August 1, 2024, and later receive a pro-rated contribution based on their CDHP
coverage effective date.
Under no circumstances will a participant who received contributions during the Plan Year be
eligible for additional contributions due to reinstatement of coverage or changing from the CDHP
with an HSA to the CDHP with a HRA or vice versa.
Reinstated employees who return to active employment within the same Plan Year and who re-
enroll in the CDHP HRA shall have their remaining HRA fund balance reinstated. Reinstated
employees who re-enroll in the CDHP HRA more than one year after termination are not eligible
for reinstatement of HRA balance reinstatement. No additional prorating of HRA funds is
available to reinstatements unless the reinstated employee is eligible for additional prorated
funding due to adding new dependent(s).

31
One-Time HSA or HRA Funding for Active State Employees

There is additional funding for the HSA or HRA for active, state employees enrolled in a PEBP plan
on July 1, 2024.*
The entire one-time contribution for Plan Year 2025 will be available for use at the beginning of
the Plan Year on or about July 1, 2024 (subject to certain limitations, above).
HSA/HRA Contributions for Eligible State Active Employees
Tier One-Time Contribution
Legislature Appropriated One-Time Contribution

State Active Employee Only $300
State Active Employee + Spouse/Domestic $400

Partner
State Active Employee + Child(ren) $400
State Active Employee + Family $500
*One-time contribution provided to eligible active, State employees enrolled in a Plan on July 1,
2024. State employees who initially elect PEBP coverage after July 1, 2024, will receive a pro-
rated base contribution based on the tier and the coverage effective date and the months
remaining in the Plan Year.
Legislatively approved enhancements, such as HSA/HRA funding and enhanced basic life
insurance amounts may be subject to change in subsequent plan years.

32
Utilization Management
The Plan is designed to provide you and your eligible dependents with financial protection from
significant health care expenses. To enable the Plan to provide coverage in a cost-effective way,
it has a Utilization Management (UM) program designed to help control increasing health care
costs by avoiding unnecessary services, directing participants to more cost-effective treatments
capable of achieving the same or better results, and managing new medical technology and
procedures. If you follow the procedures of the Plan’s UM program, you may avoid some Out-of-
Pocket costs.
The Plan’s UM program is administered by an independent professional UM company operating

under a contract with the Plan. The name, address and telephone number of the UM company
appears in the Participant Contact Guide section. The health care professionals at the UM
company focus their review on the medical necessity of hospital stays and the medical necessity,
appropriateness, and cost-effectiveness of proposed medical or surgical services. In carrying out
its responsibilities under the Plan, the UM company has been given discretionary authority by
the Plan administrator to determine if a course of care or treatment is medically necessary with
respect to the patient’s condition and within the terms and provisions of the Plan.
The UM program is not intended to diagnose or treat medical conditions, validate eligibility for
coverage, or guarantee payment of Plan benefits. Eligibility for and actual payment of benefits
are subject to the terms and conditions of the Plan as described in this document, PEBP’s Active
Employee Health and Welfare Wrap Plan, and Retiree Health and Welfare Wrap Plan documents.
For example, benefits would not be payable if your eligibility for coverage ended before the
services were rendered, or if the services were not covered, either in whole or in part, by an
exclusion in the Plan.
Even if your physician recommends surgery, hospitalization, confinement in a skilled nursing or

sub-acute facility, or your physician or other provider proposes or provides any medical service
or supply, the recommended services or supplies are not automatically considered medically
necessary for purposes of determining coverage under the Plan.
PEBP, the third-party claim administrator, and the UM company are not engaged in the practice
of medicine and are not responsible for the outcomes of health care services rendered (even if
the health care services have been authorized by the UM company as medically necessary), or
for the outcomes if the patient chooses not to receive health care services that have not been
authorized by the UM company as medically necessary.
When reviewing services for appropriateness of care and medical necessity, the UM company
uses guidelines and criteria published by nationally recognized organizations, along with medical
judgement of licensed heath care professionals.

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Delivery of Services
You are entitled to receive medically necessary medical care and services as specified in this
Plan’s Schedule of Benefits. These include medical, mental health, behavioral health, surgical,
diagnostic, therapeutic, and preventive services. If a precertification is required and you do not
obtain the required precertification, the service may not be covered, even if the service is
medically necessary.
Concurrent Review
Concurrent review (sometimes referred to as a continued stay review) is the ongoing assessment
of health care as it is being provided, especially (but not limited to) inpatient confinement in a
hospital or skilled nursing or sub-acute facility. When you are receiving medical services in a
hospital or other inpatient facility, the UM company monitors your stay by contacting your
physician or other providers to assure that continuation of medical services in the facility is
medically necessary. The UM company will also help coordinate your medical care with other
healthcare benefits available under the Plan.
Concurrent review may include such services as coordinating home health care or durable
medical equipment, assisting with discharge plans, determining the need for continued medical
services, or advising your physician or other providers of various options and alternatives for your
medical care available under this Plan.
If at any point, your stay is found not to be medically necessary and care could be safely and
effectively delivered in another environment (such as through home health care or in another
type of health care facility), you and your physician will be notified. This does not mean that you
must leave the hospital, but if you choose to stay, expenses incurred after the notification will be
your responsibility. If your hospital stay is determined not to be medically necessary, no benefits
will be paid on any related hospital, medical or surgical expense. You may also appeal the
determination (refer to the Appealing a Utilization Management Determination section).
Retrospective Review
Retrospective Review is the review of health care services after they have been provided to
determine if those services were medically necessary. The Plan will pay benefits only for those
days or treatment that would have been authorized under the utilization management program.
Case Management
Case management is a voluntary process administered by the UM company. Its professionals
work with the patient, the patient’s family, caregivers, providers, the third-party claims
administrator, and the Plan Administrator or its designee to coordinate a quality, timely and cost-
effective treatment program. Case management services are particularly helpful when the
patient needs complex, costly and/or high-technology services, or when assistance is needed to
guide the patient through a maze of potential providers. Case management is available for sickle
cell disease and its variants, see NRS 695G.174, as well as for a disability resulting from a mental
health or substance use disorder diagnosis, among other conditions.

34
The case manager will work directly with your physician, hospital, and/or other provider to
review proposed treatment plans and to assist in coordinating services and obtaining discounts
from providers as needed. From time to time, the case manager may confer with your physician
or other providers and may contact you or your family to assist in making plans for continued
health care services or obtaining information to facilitate those services.
You, your family, or your physician may call the case manager at any time to ask questions, make
suggestions or offer information. The case manager can be reached by calling the UM company
at the telephone number shown in the Participant Contact Guide section or on the PEBP website
at https://pebp.nv.gov/.
Precertification (Prior Authorization) Process

Precertification or prior authorization review is a procedure administered by the UM company to
assure health care services meet or exceed accepted standards of care. In certain cases, as set
forth below, for a benefit to be covered, the UM company must approve and/or pre-certify the
service. If a precertification is required and you do not obtain the required precertification, the
benefits may be reduced, even if the service is medically necessary. The UM company uses
nationally recognized guidelines and criteria as standard measurement tools to determine
whether benefits are approved and/or pre-certified.
Precertification also includes the determination of whether the admission and length of stay in a
hospital or skilled nursing or sub-acute facility, surgery or other health care services are medically
necessary and if the location of service is high quality and lowest cost.
A precertification is required for referrals to physicians and providers for certain services.
Benefits listed in this Plan may be subject to precertification requirements and concurrent or
retrospective review depending upon the circumstances associated with the services. Refer to
the Services Requiring Precertification section below for more information.
Failure to obtain precertification may result in your benefits being reduced or denied (see the
Failure to Follow Required Utilization Management Procedures in this section).
Services Requiring Precertification (Prior Authorization)

Inpatient Admissions
• Acute inpatient or observation
• Long-Term Acute Care
• Rehabilitation
• Behavioral Health
• Transplant including pre-transplant related expenses
• Skilled Nursing facility and sub-acute facility
• Residential Treatment Facility and partial residential treatment programs
• Hospice (inpatient/outpatient) exceeding six (6) months.
• Obstetric – (precertification only required if days exceed 48 hours for vaginal
delivery or 96 hours for a C-section)

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• Intraoperative Neuro Monitoring

• Surgeries to treat Gender Dysphoria
• Bariatric/weight loss surgeries at Centers of Excellence and adjustments to lap
bands after the first 12 months post-surgery
Outpatient and Physician – Surgery

When outpatient and physician surgery is performed at an In-Network, contracted ambulatory
surgical center (ASC) by an In-Network, contracted physician, prior authorizations is not required.
However, when services are not performed at an In-Network, contracted ASC, procedures will
require prior authorization. Examples of services that require prior authorization include, but are
not limited to:
• Back Surgeries and hardware related to surgery
• Total and remaining Hip and Knee Surgeries
• Biopsies (excluding skin, colonoscopy and upper GI endoscopy biopsy, upper GI
endoscopy diagnosis)
• Thyroidectomy, Partial or Complete
• Open Prostatectomy
• Frenectomy
• Oophorectomy, unilateral and bilateral
• Hysterectomy (including prophylactic)
• Autologous chondrocyte implantation, Carticel
• Transplant (excluding cornea)
• Balloon sinuplasty
• Surgeries to treat Gender Dysphoria
• Bariatric/weight loss surgeries at Centers of Excellence and adjustments to lap
bands after the first 12 months post-surgery
• Sleep apnea related surgeries, limited to:
o Radiofrequency ablation (Coblation, Somnoplasty)
o Uvulopalatopharyngoplasty (UPPP) (including laser-assisted procedures)
• Mastectomy (including gynecomastia and prophylactic) and reconstruction
surgery
• Orthognathic procedures (e.g., Genioplasty, LeFort osteotomy, Mandibular ORIF,
TMJ)
• Varicose vein surgery/sclerotherapy
• Any procedure deemed to be Experimental and/or Investigational (provider must
indicate on the pre-certification request that the service/procedure is
Experimental and/or Investigational and/or part of a clinical trial).
• Intraoperative Neuro Monitoring
• Prophylactic surgery
Outpatient and Physician – Diagnostic Services

• Advanced high-tech imaging services (for example, CT, PET, SPEC, MRI, etc.)

36
• Capsule endoscopy
• Genetic testing including:
o BRCA
o Biomarker testing for the diagnosis, treatment, appropriate management, and
ongoing monitoring of cancer when such biomarker testing is supported by the
medical and scientific evidence.
▪ Requests for precertification for biomarker testing will be responded to within
72 hours after receipt, or within 24 hours if the provider indicates the request
is urgent.
Outpatient and Physician – Continuing Care Services

• Applied Behavior Analysis (ABA) Therapy for Medical, Mental Health, and Substance Use
Disorder
• Electroconvulsive Therapy (ECT)
• Transcranial Magnetic Stimulation (TMS)
• Chemotherapy
o Oral Chemotherapy to be reviewed by Pharmacy Benefit Manager
• Radiation Therapy
• Oncology and transplant related injections, infusions, and treatments (e.g., CAR-T,
endocrine and immunotherapy), excluding supportive drugs (e.g., antiemetic and
antihistamine)
• Hyperbaric Oxygen
• Home Health Care
• Durable Medical Equipment exceeding $1,000
o prior authorization is based on overall cost to the plan and/or purchase price, not
the amount billed for monthly rental. DME rental to purchase in accordance with
Medicare guidelines.
• Non-Emergency Medical Transportation – scheduled air and ground facility to facility
and interstate
• Injectables and infusions excluding services reviewed by the PBM
• Intensive Outpatient Programs, including partial hospitalization programs
• Sickle Cell Disease
• Vein Therapy
• Habilitative and rehabilitative therapy (physical, speech, occupational) exceeding a visit
limit of 90 visits between the types of therapy per Plan Year.
o Visit limits will not apply to medically necessary treatment of mental health or
substance use disorder.
Services Not Requiring Precertification (Prior Authorization)

Prior authorization is not required for medically necessary emergency services when a medical
condition that manifests itself by symptoms of such severity (including severe pain) that a
prudent layperson who possesses an average knowledge of health and medicine could
reasonably expect that the absence of immediate medical attention could result in:

37
• Serious jeopardy to the health of the participant;

• Serious jeopardy to the health of an unborn child;
• Serious impairment of a bodily function; or
• Serious dysfunction of any bodily organ or part.
The UM company must be notified of an emergency hospital admission within one business day
so the UM company can conduct a concurrent review. Your physician or the hospital should call
the UM company to initiate the concurrent review. Even though a precertification may not be
required for some services, the hospital or facility is still required to comply with the Plan’s
provisions regarding UM, such as concurrent review.
How to Request Precertification (Prior Authorization)

It is your responsibility to ensure that precertification occurs when it is required by the Plan. Any
penalty or denial of benefits for failure to obtain precertification is your responsibility, not the
provider’s. Your physician must call the UM company at the telephone number shown in the
Participant Contact Guide to request precertification. Calls for elective services should be made
at least 15 calendar days before the expected date of service or may be subject to the benefit
reduction listed in the Utilization Management section. The UM company will require the
following information:
• The employer’s name;
• Employee’s name;
• Patient’s name, address, phone number and Social Security Number or PEBP
unique ID;
• Physician’s name, phone number or address;
• The name of any hospital or outpatient facility or any other provider that will be
providing services;
• The reason for the health care services or supplies; and
• The proposed date for performing the services or providing the supplies.
The UM company will review the information and provide a determination to you, your physician,
the hospital or other provider, and the third-party claims administrator as to whether the
proposed health care services have been determined to be medically necessary. Additionally, the
UM company may approve medical necessity but not site of care. In these circumstances, the
UM company will provide approved alternate locations to the caller. While industry and
accreditation standards require a preauthorization determination within 15 calendar days for a
non-urgent case, the UM company will usually respond to your physician or other provider by
telephone within (5) five business days of receipt of the request. The determination will then be
confirmed in writing.
If your hospital admission or medical service is determined not to be medically necessary, you
and your physician will be given recommendations for alternative treatment. You may also
pursue an appeal (refer to the Appealing a Utilization Management Determination section).

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Centers of Excellence Benefit (Voluntary)

Participants in the CDHP have access to the Centers of Excellence Benefit, which is a special
surgery benefit that provides access to Centers of Excellence and concierge services. Through the
Centers of Excellence Benefit, participants have access to specialized providers and facilities
selected for their expertise in selected procedures, as well as assistance with travel,
communication, and other non-medical matters relating to those procedures.
Currently, participants may use the Centers of Excellence Benefit for procedures such as:
• Total, partial, and revision hip and knee replacement surgery

• Spinal fusion surgery
• Bariatric (weight loss) surgery
• Other orthopedic and spine procedures (e.g., hand, wrist, elbow, shoulder, ankle, foot)
• Cardiac (heart) surgery
• Oncology
This benefit generally pays all eligible expenses after the CDHP participant satisfies the applicable
deductible. For details of how this benefit works, covered expenses, and limitations and
disclosures, please see the Centers of Excellence Wrap Plan Document online at
https://pebp.nv.gov/.
The vendor currently coordinating the Centers of Excellence Benefit, Carrum Health, will
determine if a member is eligible to participate in the benefit, and this determination is separate
from the Utilization Management process described elsewhere. If you would like to use the
Center of Excellence Benefit, please contact Carrum Health.
Second Opinion
The utilization management company may authorize a second opinion upon your request in
accordance with this Plan. Examples of instances where a second opinion may be appropriate
include:
• Your physician has recommended a procedure and you are unsure whether the
procedure is necessary or reasonable;
• You have questions about a diagnosis or plan or care for a condition that threatens
substantial impairment or loss of life or bodily functions;
• You are unclear about the clinical indications about your condition;
• A diagnosis is in doubt due to conflicting test results;
• Your physician is unable to diagnose your condition; and
• A treatment plan in progress is not improving your medical condition within a
reasonable period.
A participating provider, including your primary care physician, may notify the UM company on
your behalf to obtain precertification (prior authorization) for the services described in Services
Requiring Precertification (Prior Authorization).

39
2nd.MD
2nd.MD is PEBP’s preferred second opinion Service. See benefits in the Schedule of Benefits,
below, for additional information.
Hospital Admission
You are responsible for ensuring the UM company is notified at least 5 (five) business days before
an inpatient admission to obtain pre-certification.
Your physician or other provider may notify the UM company, but it is ultimately your
responsibility to make sure they are notified. The UM company will review the
physician/provider’s recommendation and treatment plan to determine the level of care and
place of service. If the UM company denies the precertification for hospital admission as not
covered or determines that the services do not meet the UM company’s medical necessity
criteria, the Plan’s third-party administrator will only pay benefits for inpatient that has been pre-
certified.
You are required to obtain a precertification before you obtain services for inpatient elective
surgeries. If you do not follow the required UM process, benefits for the elective surgeries may
be reduced by 50% of this Plan’s Maximum Allowable Charge. This provision applies to both In-
Network and Out-of-Network surgery expenses. Expenses related to the penalty will not be
counted to meet your Out-of-Pocket Maximum, if applicable.
Emergency and Urgent Hospital Admission

Emergency and Urgent Hospital Admissions include complications of pregnancy.
You are not required to obtain a precertification before you obtain services for a medical
emergency. However, the UM company must still be notified within 24 hours, the next business
day, or as soon as reasonable after admission so the UM company can conduct a concurrent
review. If you are incapacitated and you (or a friend or relative) cannot notify the UM company
within the above stated times, they must receive notification as soon as reasonably possible after
the admission or you may be subject to reduction or denial of benefits as provided by the Plan.
• Emergency Hospital Admission: Admission for hospital confinement that results
from a sudden and unexpected onset of a condition that requires medical or
surgical care. In the absence of such care, you could reasonably be expected to
suffer serious bodily injury or death. Examples of emergency hospital admission
include, but are not limited to, admissions for heart attacks, severe chest pain,
burns, loss of consciousness, serious breathing difficulties, spinal injuries, and
other acute conditions.
• An urgent hospital admission means an admission for a medical condition
resulting from injury or serious illness that is less severe than an emergency
hospital admission but requires care within a short time, including complications
of pregnancy.

40
Even though a precertification may not be required for some services, the hospital or facility is
still required to comply with the Plan’s provisions regarding utilization management, such as
concurrent review.
If you do not follow the required UM process, benefits payable for the services may be reduced
by 50% of this Plan’s Maximum Allowable Charge. This provision applies to both In-Network and
Out-of-Network medical expenses. Expenses related to the penalty will not be counted to meet
your Out-of-Pocket Maximum.
Confinement in an Out-of-Network Hospital Following an Emergency Admission

Please refer to the No Surprises Act section of this document for claims subject to that Act. For
all other confinements, if you are confined in an Out-of-Network hospital after you receive
emergency services, the UM company must be notified within 24 hours, the next business day,
or as soon as reasonable after admission. The UM company may determine it is appropriate to
transfer you to an In-Network hospital as soon as it is medically appropriate to do so. If you
choose to stay in the Out-of-Network hospital after the date the UM company decides a transfer
is medically appropriate, the Plan will pay Eligible Medical Expenses at the Out-of-Network
benefit level, subject to the Plan’s Maximum Allowable Charge if the continued stay is authorized
by the UM company and determined to be a covered service.
Other Exceptions
If you receive ancillary services such as an x-ray, laboratory services, or anesthesia services from
an Out-of-Network provider while receiving services at an In-Network inpatient or outpatient
facility (such as an outpatient surgery center), the Plan will cover the Eligible Medical Expenses
at the In-Network benefit level, subject to the Plan’s Maximum Allowable Charge.
Elective Knee and Hip Joint Replacement – Nevada Exclusive Hospitals and Outpatient
Surgery Centers
Precertification is required; the UM company will review the request based on surgery type,
medical necessity, covered benefits, provider quality, cost, and provider location.
Due to cost variations for elective knee and hip joint replacement performed in Nevada, the
third-party claims administrator has identified exclusive providers who meet the Plan’s cost
threshold for routine knee and hip replacement procedures. The exclusive provider list can be
found on the PEBP website.
If you choose a provider on the exclusive list, you will potentially reduce your out-of-pocket costs
in accordance with the standard plan benefits.
However, if you choose to use a non-exclusive provider, the Plan will pay benefits in accordance
with its cost threshold or Maximum Allowable Charge. You may be subject to balance billing for
any amount exceeding this Plan’s cost threshold. Amounts exceeding the Plan’s established
threshold will not apply to your Deductible (if applicable) or Out-of-Pocket Maximum.

41
Inpatient or Outpatient Surgery

You are responsible for ensuring that the UM company is notified at least 5 (five) business days
before elective inpatient or outpatient surgery is performed to ensure that it is covered.
Your physician or other provider may notify the UM company, but it is your responsibility to
make sure they are notified. The UM company will review the physician’s recommended course
of treatment to ensure the requested treatment meets established medical necessity criteria
and protocols.
The claims administrator will only pay benefits for inpatient or outpatient surgery that is pre-
certified, and the services/supplies are a covered benefit.
Outpatient Infusion Services

Precertification is required for outpatient infusion services. The UM company will review the
request based on covered benefits, medical necessity, provider quality, cost, and location. If you
choose to receive your infusion at a non-exclusive hospital or infusion center, you will be
responsible for any amount that exceeds this Plan’s Maximum Allowable Charge. Amounts
exceeding this Plan’s established cost threshold will not apply to your annual Deductible or Out-
of-Pocket Maximum.
Air Ambulance Services

This Plan provides coverage for emergency air ambulance and inter-facility patient air transport
if there is a life-threatening situation, or the service is deemed medically necessary by the UM
company. The air ambulance services are subject to cost-share (Deductible, Copay, or
Coinsurance) if applicable.
See the Utilization Management section for air ambulance precertification requirements.
Air/Flight Schedule Inter-Facility Transfer

All inter-facility transport services require precertification. The UM company may discuss with
the physician and/or hospital/facility the diagnosis and the need for inter-facility patient
transport versus alternatives. Failure to obtain a precertification may result in a reduction or
denial of benefits for charges arising from or related to flight-based inter-facility transfers. Non-
compliance penalties imposed for failure to obtain a precertification will not be included as part
of the annual out-of-pocket maximum.
Inter-facility transport may occur if there is a life-threatening situation, or if the transport is

deemed medically necessary. The following conditions apply:
• Services via any form of air/flight for inter-facility transfers must be pre-certified
before transport of the participant to another hospital or facility, and the
participant is in a hospital or other health care facility under the care or
supervision of a licensed health care provider; and

42
• Inaccessibility to ground ambulance transport or extended length of time required

to transport the patient via ground ambulance transportation could endanger the
patient.
Emergency Air Ambulance

This Plan provides coverage for emergency air ambulance transportation for participants whose
medical condition at the time of pick-up requires immediate and rapid transport due to the
nature and/or severity of the illness/injury. Air ambulance transportation must meet the
following criteria:
• Services via any form of air/flight for emergency air ambulance; and
• The patient’s destination is an acute care hospital; and
• The patient’s condition is such that the ground ambulance (basic or advanced life
support) would endanger the patient’s life or health; or
• Inaccessibility to ground ambulance transport or extended length of time required
to transport the patient via ground ambulance transportation could endanger the
patient.
See Ambulance section for details on plan benefits and coverage.
Gender Dysphoria
The Plan provides benefits for the medically necessary treatment of conditions relating to gender
dysphoria and gender incongruence, including medically necessary psychosocial and surgical
intervention and any other medically necessary treatment for such disorders.
The participant or their physician must contact the UM company to begin the process toward
surgical intervention to treat gender dysphoria. The initial contact will include:
• Notification to the participant that the precertification process begins with the
initial contact to the UM company.
• Advising participants of providers who specialize in this type of treatment.
This service is provided by the UM company and will be initiated upon the first call for a
precertification. Case management services are particularly helpful for a participant or their
covered dependent who is receiving complex medical services for medical conditions such as
gender dysphoria. Your assigned case manager nurse will provide you with assistance addressing
any concerns you may have about issues such as continuity of care or finding providers or a
provider who specializes in gender dysphoria.
Health Care Services and Supplies Review

A participating provider, including your primary care physician, may notify the UM company on
your behalf to obtain precertification (prior authorization) for the services described in Services
Requiring Precertification (Prior Authorization).

43
Non-participating providers may not know the UM company to obtain precertification for
services. In such a case, you must confirm that the UM company pre-certified the service to
assure that it is covered.
The Plan will pay for covered health care services and supplies only if authorized as outlined
above. The Plan will not pay for any health care services or supplies that are not covered services
or do not meet medically necessary criteria and protocols.
Failure to Follow Required UM Procedures

If you do not follow the required precertification review process described in this section,
benefits payable for the services you failed to receive a precertification may be reduced by 50%
of the Plan’s Maximum Allowable Charge. This provision applies to both In-Network and Out-of-
Network Eligible Medical Expenses. Expenses related to the penalty will not apply to your Plan
Year Deductible or Out-of-Pocket Maximum. If you wish to appeal a decision made by the UM
company, refer to the Appealing a UM Determination section.

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Schedule of Medical Benefits
Schedule of Benefits
The Schedule of Benefits provides a description of benefits, including certain limitations under
this Plan. Covered services must be medically necessary and are subject to exclusions and
limitations as described herein. Precertification is required for many services. Plan benefit
limitations apply to certain benefit categories and out-of-network charges are not covered unless
otherwise specified in this document.
When the Plan Administrator determines that two or more courses of treatment are substantially
equivalent, the Plan Administrator reserves the right to substitute less costly services or benefits
for those that this Plan would otherwise cover.
Example: If both inpatient care in a skilled nursing facility and intermittent, part-time
nursing care in the home would be medically appropriate, and if inpatient nursing care
would be less costly, this Plan could limit coverage to the inpatient care. This Plan could
limit coverage to inpatient care even if this means extending the inpatient benefit
beyond the quantity provided in the Schedule of Benefits.
The fact that a participating provider prescribed, ordered, recommended, or approved a

service, treatment, or supply does not necessarily make it a covered service or medically
necessary.
The Schedule of Benefits should be read in conjunction with the Benefit Limitations and Exclusions
and Key Definitions Terms and Definitions. The Explanations and Limitations may not include
every limitation. For more information relating to a specific benefit, refer to Utilization
Management (for any precertification requirements), Exclusions, Key Terms and Definitions and
other sections that may apply to a specific benefit.
All claims must be submitted within twelve (12) months of the date of service to be considered
for payment.
The following services are covered services when provided by a professional.

45
Benefit Description In-Network Out-of-Network

Plan pays 50% of the Maximum
Plan pays 80% after Plan Year
Acupuncture and Acupressure Allowable Charge after Plan Year
Deductible
Deductible
Explanations and Limitations
Acupuncture and Acupressure
• Covered if performed by a licensed provider acting within the scope of their license.
• Supporting documentation establishing medical necessity will be required after 20 visits in a Plan
Year.
• Maintenance services are not a covered benefit.

Allowable Charge after Plan Year
Plan pays 80% after Plan Year Deductible, or
Allergy Services
Deductible 110% of the Medi-Span Average
Wholesale Price (AWP) after
Plan Year Deductible
Allergy Services
• Allergy services are covered only when ordered by a physician.
• Allergy sensitivity testing, including skin patch or blood tests such as Rast or Mast; Desensitization
and hypo-sensitization (allergy shots given at periodic intervals); Allergy antigen solution.
Ambulance
Play pays 80% of Maximum

Ground Ambulance Allowable Charge after Plan
Deductible
Year Deductible
Plan pays 80% after Deductible Plan pays 80%, subject to the
Air Ambulance
No Surprises Act.

Ground and Air Ambulance Services

46
Ambulance
Ground Ambulance Services: In the event of a life-threatening emergency in which a participant uses a
ground ambulance, the deductible, coinsurance, and accrual of the Out of Pocket Maximum are the
same for In-Network and Out-of-Network providers. However, benefits for Out-of-Network providers
are subject to the Plan’s Maximum Allowable Charge, which is 140% of the Medicare Allowable rate.
Because Out-of-Network providers do not have a contract with this Plan’s provider network, they may
bill the member for any amount exceeding the benefits paid.
For example, if you have already met your deductible for the plan year, you use a ground ambulance
during an emergency, the out-of-network provider bills $2,000 for the ride but the Medicare Allowable
rate for that ambulance ride is $1,000:
The Out-of-Network Ground Ambulance Provider Bills $2,000
The Plan Pays 80% of $1,000 × 140% $1,120
The Out-of-Network Provider May Bill You For $ 880
These amounts are for illustrative purposes only; the difference between what an out-of-network
Provider bills for a ground ambulance ride and the Medicare Allowable rate for that ride varies. Please
direct questions about any balance billed by the Provider to the Provider.
Air Ambulance Services: In the event of a life-threatening emergency in which a participant uses an Out-
of-Network provider, benefits will be paid at the In-Network benefit level. Out-of-Network providers
may not balance bill the member.
Transportation by a professional ground ambulance to a local hospital or transfer to the nearest facility
having the capability to treat the condition.
Air Ambulance (fixed wing/rotary) Inter-Facility Transfer
• Inter-facility patient air transport, for participants if there is a life-threatening situation or it is
deemed to be medically necessary.
• Air ambulance for scheduled inter-facility transfers must be prior authorized before transport via
any form of flight (fixed wing/rotary) to another hospital or facility.
o Failure to obtain a precertification may, at the discretion of the Plan Administrator or its
designee, result in a reduction or denial of benefits for charges arising form or related to inter-
facility patient transport via any form of flight.
o Non-compliance penalties imposed for failure to obtain precertification will not apply to the
Plan Year Deductible or Out-of-Pocket Maximum.
o As part of the precertification review, the Plan Administrator retains the discretionary authority
to limit benefit availability to alternative providers of flight-based inter-facility patient transport
if a provider fails to comply with the terms of the Plan, or the proposed charges exceed the
maximum allowable charge in accordance with the terms of this Plan.
Air Ambulance (fixed wing/rotary) Emergency

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Ambulance
• Includes coverage for emergency air ambulance transportation when a medical condition at the
time of pick-up requires immediate and rapid transport due to the nature and/or severity of the
illness/injury.
• Emergency air ambulance services must meet the following criteria:
o The patient’s destination is an acute care hospital, and
o The Patient’s condition is such that the ground ambulance (basic or advanced life support)
would endanger the patient’s life or health, or
o Inaccessibility to ground transport or extended length of time required to transport the patient
via ground ambulance transportation could endanger the patient.
• The Plan Administrator retains the discretionary authority to limit benefit availability for air
emergency ambulance and/or inter-facility patient transfer when a provider fails to comply with
the terms of this Plan, except where provided by the No Surprises Act.
See the Utilization Management section for air ambulance precertification requirements.
Autism Spectrum Disorders Plan pays 50% of the

Maximum Allowable Charge
Services Deductible
after Plan Year Deductible
Autism Spectrum Disorders Services
The Plan covers screening for and diagnosis of autism spectrum disorders and treatment of autism
spectrum disorders for covered individuals.
Excludes coverage for reimbursement to an early intervention agency or school for services delivered
through early intervention or school services.

48

Bariatric/Weight Loss Plan pays 80% after Plan Year
Not Covered
Surgery Deductible
Explanation and Limitations
Bariatric/Weight Loss Surgery
Bariatric weight loss surgery benefits, pre-and post-surgery, are available only when performed at an In-
Network Bariatric Surgery Center of Excellence facility, by an In-Network surgeon and ancillary providers.
The third-party claims administrator will determine the In-Network Bariatric Surgery Center of
Excellence facility. It is the participant’s responsibility to ensure that bariatric surgery services providers
are In-Network and facilities chosen to provide services are In-Network. Participants can verify the
network status of any provider, including a facility, by calling the third-party claims administrator. For
more information regarding Bariatric Surgery Centers of Excellence, see the Key Terms and Definitions.
Participants are limited to one obesity related surgical procedure of any type in an individual’s lifetime
while covered under any PEBP-sponsored self-funded plan. For example, a participant cannot have lap
band surgery on a PEBP-sponsored self-funded plan and then subsequently seek benefits for gastric
bypass on this Plan.
If a participant has started any type of program to meet the pre-surgery criteria outlined below with an
Out-of-Network provider (including a facility), those services will not meet the Plan’s
mandatory precertification requirements. For the Plan to consider your bariatric surgery at the In-
Network benefit level; you will have to begin the precertification process again with the appropriate In-
Network providers.
For lap band adjustments, the Plan will consider any adjustments made in the immediate 12 months
following surgery if the participant remains compliant with their post-surgical support group meetings
as verified by the UM company. Any adjustments to the lap band after the first 12 months post-surgery
will be subject to precertification.
Clinical criteria for weight loss surgeries is managed by the UM Company.
Travel Expenses:
This Plan provides reimbursement of certain costs associated with travel and lodging accommodations
for the member and one additional person (spouse/domestic partner, family member or friend) when
associated with bariatric/weight loss surgery and performed at a Center of Excellence that is located 50
or more miles from the member’s residence. For travel expense benefits, refer to the Travel
Expenses benefit section.
Expenses incurred for travel and lodging accommodations for bariatric/weight loss surgery not
performed at a Center of Excellence are not covered.

49

Behavioral Health Services Plan pays 50% of the Maximum
Mental Health and Allowable Charge after Plan
Deductible
Substance Abuse Year Deductible
Behavioral Health Services
Precertification is required for inpatient admissions, including residential treatment facilities, outpatient
partial hospitalization programs, and partial residential treatment programs.
Services and supplies for treatment of alcoholism, chemical dependency or drug addiction are covered.
Care must be provided by licensed/credentialed providers—such as hospitals or residential treatment
programs for inpatient care, and non-residential treatment programs (including hospital centers,
treatment facilities, physicians and qualified employees of the centers or facilities) for outpatient care.
Behavioral health services payable by this Plan include:
• Outpatient visits
• Acute inpatient admission
• Partial day treatment
• Partial hospitalization
• Intensive outpatient program
• Day treatment
• Psychological testing
• Detoxification
The following behavioral health practitioners are payable under the Plan: psychiatrist (MD or DO),
psychologist (Ph.D.), Masters’ prepared counselors (e.g., MSW), licensed associate in social work, social
worker, independent social worker, or clinical social worker, as well as any licensed provider providing
covered services and acting within the scope of their license.
The Plan provides benefits for intermediate levels of care for behavioral health disorders and/or
chemical dependency disorders in parity with medical or surgical care of the same level. If the Plan
provides benefits for a skilled nursing facility for medical or surgical treatment, the Plan will provide
equal behavioral health disorder and/or chemical dependency disorder benefits for intensive outpatient
therapy, partial hospitalization, residential treatment, inpatient treatment.
The provider must be licensed or approved by the state in which the services are provided. Care must
be provided by licensed, eligible providers—such as hospitals or residential treatment programs for
inpatient care and non-residential treatment programs (including hospital centers, treatment facilities,
physicians and qualified employees of the centers or facilities) for outpatient care. Precertification is
required for inpatient and outpatient care in a facility.
Outpatient prescription drugs for behavioral health are payable under the prescription drug benefits.

50

Behavioral Health Services Plan pays 50% of the Maximum
Mental Health and Allowable Charge after Plan
Deductible
Substance Abuse Year Deductible
Behavioral Health Services
For information regarding precertification requirements, benefits, and exclusions, refer to the
Utilization Management, Key Terms and Definitions, and Exclusions sections.

Blood Services for Surgery Allowable Charge after Plan
Deductible
Year Deductible
Blood Transfusions
• Blood transfusions, blood products and equipment for its administration.
• Services are covered only when ordered by a physician.
• Expenses related to autologous blood donation (patient’s own blood) are covered.

Plan pays 50% of the
Plan pays 80% after Plan Year Maximum Allowable Charge or
Chemotherapy
Deductible 110% of the Medi Span AWP,
after Plan Year Deductible
Chemotherapy
• Chemotherapy drugs and supplies administered under the direction of a physician in a hospital,
health care facility, physician’s office or at home. Covered when ordered by a physician;
chemotherapy must be pre-certified by the UM company.
• See prescription benefits for orally administered chemotherapy drugs:
• Patients undergoing chemotherapy may be eligible for 1 wig, any type, synthetic or not, per Plan
Year (excluding sales tax).

51

Chiropractic Services Plan pays 50% of the
Plan pays 80% after Plan Year Maximum Allowable
Office visit and spinal Deductible Charge after Plan Year
manipulation services Deductible
Chiropractic Services
• Services are covered if performed by a licensed provider acting within the scope of their license.
• Limited to a maximum of 20 visits per Plan Year.
• Maintenance services are not a covered benefit.
X-rays performed in conjunction with chiropractic services are payable under the Radiology Services
section of this Schedule of Benefits.

Plan pays 50% of the
Plan pays 80% after Plan Year Maximum Allowable
Clinical Trials
Deductible Charge after Plan Year
Deductible
Clinical Trials
A clinical trial is the process for testing new types of medical care that are in the final stages of
research to find better ways to prevent, diagnose or treat diseases.
• Coverage for certain treatment received as part of a clinical trial or study for treatment of
cancer or chronic fatigue syndrome will be provided subject to the requirements and
limitations set forth in NRS 695G.173.
• Precertification must be obtained from the UM company.

Corrective Appliances
Prosthetic & Orthotic Plan pays 50% of the
Devices, Maximum Allowable Charge
Deductible
other than dental after Plan Year Deductible

• Coverage is provided for certain corrective appliances that are medically necessary and FDA
approved. This Plan pays for the purchase of standard models at the option of the Plan. There is
coverage for repair, adjustment, or servicing of the device or, replacement of the device due to a
change in the covered person’s physical condition that makes the original device no longer

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Corrective Appliances
Prosthetic & Orthotic Plan pays 50% of the
Devices, Maximum Allowable Charge
Deductible
other than dental after Plan Year Deductible

functional or if the device cannot be satisfactorily repaired.
• Prosthetics such as limbs and ocular; orthotics such as casts, splints and other orthotic devices used
in the reduction of fractures and dislocations; colostomy or ostomy (Orthotic) supplies, hearing aid*
(with limitations, see Hearing Aids section).
• Plan allows up to $120 for one set of lenses (contacts or frame-type) for the treatment of glaucoma
or when required following cataract surgery. This includes soft lenses or sclera shells intended as
corneal bandages for patients without the lens of the eye (aphakic).
Corrective appliances are covered only when ordered by a physician or health care practitioner.
Orthopedic shoes and foot orthotics are not a covered benefit unless the shoe or foot orthotic is
permanently attached to a brace.
*Hearing aids: To help determine what prosthetic or orthotic appliances are covered, see the definitions
of “Prosthetics” and “Orthotics” in the Key Terms and Definitions section.
Diabetes Care Management Disease Program (DCM) (Enhanced Benefits)
Two office visits covered at 100% Plan pays 50% of the Maximum
Office Visits per Plan Year, not subject to Allowable Charge after Plan
Deductible Year Deductible
Laboratory Test
Two routine lab tests covered at Plan pays 50% of the Maximum
(must be performed using a
100% per Plan Year, not subject Allowable Charge after Plan
free-standing non-hospital-
to Deductible Year Deductible
based laboratory)
Preferred Retail Smart90 Retail
Network or ESI Home
Retail 30-Day Delivery
Supply 90-Day Supply
Preferred Generic $5 Copay $15 Copay Not covered
Preferred Brand $25 Copay $75 Copay Not covered

53
Non-Preferred Brand 100% copay Not covered

ESI Home Delivery Pharmacy:
Diabetic Supplies
90-Day Supply
(test strips, insulin syringes, Not covered
$50 Copay per supply item or the
alcohol pads, and lancets)
lessor of actual cost
ESI Home Delivery: $0 Copay
Blood Glucose Monitor Not covered
(limited to one per Plan Year)
Diabetes Care Management Disease program (enhanced benefits)
The Diabetes Care Management (DCM) program is a voluntary opt-in disease management program that
provides enhanced benefits to participants diagnosed with diabetes, and who are enrolled in and actively
engaged in the program. Benefits provided under the DCM program are not subject to deductible if
determined to be preventive under the ACA and IRS guidelines. To enroll:
• Obtain the DCM form by logging into the E-PEBP Portal at https://pebp.nv.gov/, or contact the
third-party claims administrator to request the DCM enrollment form. Complete the required
information and have your physician sign the form. Send the form to the third-party claims’
administrator for processing.
• The effective date of the DCM program will begin on the first day of the month following the
third-party claims administrator’s receipt and processing of the DCM enrollment request.
• To continue receiving the DCM enhanced benefits, a new DCM form must be completed annually,
at the start of, or prior to, the new plan year. This form must be signed by both you and your
physician and submitted to the third-party claims’ administrator for processing.
Enrolled DCM participants must comply with the following requirements to receive the enhanced
benefits:
• Complete two office visits each Plan Year for a primary diagnosis of diabetes with your primary
care physician or endocrinologist.
• Comply with the diabetes medications as prescribed by your physician.
• Complete the appropriate laboratory testing as ordered by your physician.
• Must remain compliant with your physician’s prescribed treatment plan in the Diabetes Care
Management program.
Enhanced In-Network benefits in the DCM Program include:

• Two physician office visits per Plan Year are paid at the 100% benefit level when billed with a
primary diagnosis of diabetes (additional office visits are subject to deductible and coinsurance).

54
• Two routine laboratory hemoglobin (A1c) blood tests are paid at the 100% benefit level per Plan
Year (additional lab services are subject to deductible and coinsurance).
• Diabetes-related medications, such as insulin and Metformin, are eligible for copayments listed in
the DCM Pharmacy Benefits and not be subject to the Plan Year Deductible.
• One glucose monitor, per Plan Year at $0 copayment available through the Pharmacy Benefit
Manager.
• Diabetic supplies including test strips, lancets, insulin syringes and alcohol pads are eligible for
purchase for the lessor of a $50 copay per 90-day supply item, or the cost of the item, when
coordinated through the Pharmacy Benefit Manager’s Home Delivery program.
• Copayments for Tier 1 (Generic) and Tier 2 (Preferred Brand) drugs apply to the Plan Year
Deductible and Out-of-Pocket Maximum.
• Copayments made while enrolled in the DCM program apply to the Plan Year Deductible and Out of
Pocket Maximum.
Laboratory services must be performed at an independent (non-hospital-based laboratory) to

be covered by this Plan. Refer to the Laboratory Outpatient Services section in the Schedule of
Benefits.
Other limitations:
• Diabetes Medications: Preferred Retail Network Pharmacies, Smart90 Retail, and Express Scripts
Home Delivery Program requirements apply. Refer to the Schedule of Prescription Drug Benefits for
coverage limitations, cost implications and details regarding these programs.
• Participants who are not enrolled or non-compliant in the DCM Program receive the standard
CDHP benefits. The effective date of the return to the standard CDHP benefits will be the first day
of the month following the non-compliance determination by the third-party claims administrator.
• Specialty medications are not eligible for enhanced benefits under this program and are subject to
the standard CDHP benefits.
• This Plan does not coordinate prescription drug benefits.
• Medications purchased at Out-of-Network pharmacies are not covered under this Plan.
Diabetes Education Services This Plan pays 80% after Plan
Not Covered
Year Deductible
Diabetes Education Services
• Diabetes training and education services are payable when requested by a physician and are
medically necessary for the self-care and self-management of a person with diabetes. Services must
be provided by a certified diabetes educator or a health care practitioner. Included in this benefit is
retraining due to new techniques for the treatment of diabetes or when there has been a significant
change in the person’s clinical condition or symptoms that requires modification of self-
management techniques.

55

• Some diabetic supplies are payable under the Prescription Drug section of this document. Please
contact the prescription drug Plan Administrator for more information.
• This Plan pays enhanced benefits for participants enrolled in and actively engaged in the Diabetes
Care Management (DCM). For information regarding the DCM program and the enhanced benefits,
refer to the Disease Management section and to the Schedule of Benefits for the Diabetes Care
Management Program.

Dialysis Allowable Charge after Plan
Deductible
Year Deductible

Dialysis
• Hemodialysis or peritoneal dialysis and supplies.
• Covered when ordered by a physician and administered in a hospital, health care facility, and
physician’s office or at home. Outpatient, inpatient or home dialysis must be prior authorized by
PEBP’s utilization management company.
• See the Utilization Management information.

Durable Medical Equipment Plan pays 50% of the Maximum
Allowable Charge after Plan
(DME) Deductible
Year Deductible

Durable Medical Equipment (DME)
• DME requires precertification by the UM company when the cost is expected to exceed $1,000.
• Rental of DME will be subject to Medicare guidelines concerning rental to purchase criteria.
• Repair or maintenance of standard models at the option of the Plan to include equipment
maintenance agreements.
o Repair, adjustment or servicing or medically necessary replacement of the DME due to
a change in the covered person’s physical condition, or if the equipment cannot be
satisfactorily repaired.

56

• DME, including but not limited to, insulin pumps, insulin supplies, oxygen, equipment, and supplies
required for its administration, is covered only when its use is medically necessary, and it is ordered
by a physician or health care practitioner.
• Certain blood glucose monitors are covered under this Plan. In-Network, the Plan pays 80% after
the Plan Year Deductible.
• Participants enrolled in and actively engaged in the Diabetes Care Management Program are
eligible to receive one glucose monitor each Plan Year at no cost in accordance with the DCM
Program requirements, refer to the Diabetes Care Management Disease Program section.
• Rental to purchase following Medicare guidelines for certain lifelong DME. Examples of lifelong
durable medical equipment include, but are not limited to, CPAP and BiPAP machines, and electric
wheelchairs. Please check with PEBP’s third-party claims administrator or utilization management
company for assistance. Contact the third-party claims administrator for the purchase of certain
DME such as breast pumps.
See the Exclusions section related to corrective appliances and durable medical equipment. To help
determine what durable medical equipment is covered, see the definition of “Durable Medical
Equipment” in Key Terms and Definitions, below.
Emergent and Urgent Care Services

Emergency Room Allowable Charge after Plan Year
Deductible
Deductible
Urgent Care Services Allowable Charge after Plan Year
Deductible
Deductible
Emergent and Urgent Care Services
Emergency Services
Emergency Services are covered:
Without the need for a prior authorization determination, even if the services are provided
out-of-network;
Without regard to whether the health care provider furnishing the Emergency Services is a
PPO provider or a PPO emergency facility, as applicable, with respect to the services;
Without imposing any administrative requirement or limitation on out-of-network
Emergency Services that is more restrictive than the requirements or limitations that
apply to Emergency Services received from PPO providers and PPO emergency facilities;

57

Without imposing cost-sharing requirements on out-of-network Emergency Services that are
greater than the requirements that would apply if the services were provided by a PPO
provider or a PPO emergency facility;
By calculating the cost-sharing requirement for out-of-network Emergency Services
consistent with the requirements of the federal No Suprises Act; and
By counting any cost-sharing payments made by the participant or beneficiary with respect
to the Emergency Services toward any in-network deductible or in-network out-of-pocket
maximums applied under the plan (and the in-network deductible and in-network out-of-
pocket maximums are applied) in the same manner as if the cost-sharing payments were
made with respect to Emergency Services furnished by a PPO provider or a PPO
emergency facility.
Your cost sharing amount for Emergency Services from Non-PPO Providers will be based on the lesser of
billed charges from the provider or the Qualified Payment Amount (QPA).
This Plan complies with the federal No Surprises Act, which provides patients who receive emergency
services at hospitals, independent freestanding emergency departments, and air ambulances with
certain protections against surprise medical bills. In addition, the law protects patients who receive
emergency services from out-of-network providers at in-network facilities. Members receiving such
services will only be responsible for paying their in-network cost sharing and cannot be balance billed by
the provider or facility for emergency services.
Post Stabilization Services
Emergency Services furnished by an out-of-network provider or out-of-network emergency facility
(regardless of the department of the hospital in which such items or services are furnished) also includes
post stabilization services and as part of outpatient observation or an inpatient or outpatient stay related
to the emergency medical condition, until:
The provider or facility determines that the participant or beneficiary is able to travel using
nonmedical transportation or nonemergency medical transportation; and
The participant or beneficiary is supplied with a written notice, as required by federal law,
that the provider is an out-of-network provider with respect to the Plan, of the
estimated charges for your treatment and any advance limitations that the Plan may put
on your treatment, of the names of any in-network providers at the facility who are able
to treat you, and that you may elect to be referred to one of the participating providers
listed; and
The participant or beneficiary gives informed consent to continued treatment by the
nonparticipating provider, acknowledging that the participant or beneficiary
understands that continued treatment by the nonparticipating provider may result in
greater cost to the participant or beneficiary.

58
Non-Emergency Items or Services from a Non-PPO Provider at a PPO Facility

With regard to non-emergency items or services that are otherwise covered by the Plan, if the covered
non-emergency items or services are performed by an out-of-network provider at an in-network
facility, the items or services are covered by the plan:
With a cost-sharing requirement that is no greater than the cost-sharing requirement that
would apply if the items or services had been furnished by an in-network provider;
By calculating the cost-sharing requirements consistent with the federal No Surprises Act;
and
By counting any cost-sharing payments made by the participant or beneficiary toward any
in-network deductible and in-network out-of-pocket maximums applied under the plan
(and the in-network deductible and out-of-pocket maximums must be applied) in the
same manner as if such cost-sharing payments were made with respect to items and
services furnished by an in-network provider.
Non-emergency items or services performed by an out-of-network provider at an in-
network facility will be covered based on out-of-network coverage if:
o At least 72 hours before the day of the appointment (or 3 hours in advance of
services rendered in the case of a same-day appointment), the participant or
dependent is supplied with a written notice, as required by federal law, that the
provider is an out-of-network provider with respect to the Plan, of the estimated
charges for your treatment and any advance limitations that the Plan may put on
your treatment, of the names of any in-network providers at the facility who are
able to treat you, and that you may elect to be referred to one of the in-network
providers listed; and
o The participant or dependent gives informed consent to continued treatment by the
out-of-network provider, acknowledging that the participant or beneficiary
understands that continued treatment by the out-of-network provider may result in
greater cost to the participant or beneficiary.
The notice and consent exception does not apply to Ancillary services and items or services
furnished as a result of unforeseen, urgent medical needs that arise at the time an item or
service is furnished, regardless of whether the out-of-network provider satisfied the notice and
consent criteria, and therefore these services will be covered:
o With a cost-sharing requirement that is no greater than the cost-sharing
requirement that would apply if the items or services had been furnished by an in-
network provider,
o With cost-sharing requirements calculated consistent with the federal No Suprises
Acr, and

59

o With cost-sharing counted toward any in-network deductible and in-network out of
pocket maximums, as if such cost-sharing payments were with respect to items and
services furnished by an in-network provider.
Your cost sharing amount for Non-emergency Services at in-network facilities by out-of-network
providers will be based on the lessor of billed charges from the provider or the Qualifying Payment
Amount.
Air Ambulance Services
If you receive air ambulance services that are otherwise covered by the Plan from an out-of-
network provider, your cost-sharing requirement will be the same as if the services had been
furnished by an in-network provider, and your payments will count toward your in-network
deductible and network out-of-pocket maximum. In general, you cannot be balance-billed for
air ambulance services.
Payments to Out-of-Network Providers and Facilities

The Plan will make an initial payment or notice of denial of payment for emergency services, non-
emergency services at in-network facilities by out-of-network providers, or air ambulance services
within 30 calendar days of either receiving a clean claim from the out-of-network provider or the date
the plan receives the information necessary to decide the claim.
If a claim is subject to the No Surprises Act, the participant cannot be required to pay more than the
cost-sharing required under the Plan, and the provider or facility is prohibited from billing the participant
or dependent in excess of the required cost-sharing.
External Review
An adverse benefit determination related to an emergency service, non-emergency service provided by
an out-of-network provider at an in-network facility, or air ambulances services covered under the No
Surprises Act is eligible for External Review. Please see the External Review section further information.
Continuity of Coverage
If you are a Continuing Care Patient, and the contract with your in-network provider or facility
terminates, or your benefits under a group health plan are terminated because of a change in terms of
the providers’ and/or facilities’ participation in the plan:
• You will be notified in a timely manner of the contract termination and of your right to
elect continued transitional care from the provider or facility; and
• You will be allowed up to ninety (90) days of continued coverage at in-network cost
sharing to allow for a transition of care to an in-network provider.

60

Consistent with NRS 695G.164, the Plan provides coverage for continued medical treatment for a
medical condition from a provider of health care whose contract with the insurer is terminated during
active medically necessary treatment. Unless excepted, this is until the later of:
• The 120th day after the date the contract is terminated; or
• If the medical condition is pregnancy, the 45th day after
o The date of delivery; or
o If the pregnancy does not end in delivery, the date of the end of the pregnancy.
Incorrect Provider Information

A list of in-network providers is available to you by visiting PEBP’s website or by calling the phone number
on your ID card. The network consists of providers, including hospitals, of varied specialties as well as
general practice. If you obtain and rely upon incorrect information about whether a provider is an in-
network provider from the Plan or its administrators, the Plan will apply in-network cost-sharing to your
claim, even if the provider was out-of-network.

Enteral Formula and Special Plan pays 50% of the Maximum
Food Products Allowable Charge after Plan Year
Deductible; with benefit
Deductible; with benefit
limitations
limitations
Special Food Product and Enteral Formula
The Plan covers enteral formulas and special food products for use at home that are prescribed or
ordered by a physician as medically necessary for the treatment of inherited metabolic diseases
characterized by deficient metabolism, or malabsorption originating from congenital defects or defects
arising shortly after both, of amino acid, organic acid, carbohydrate, or fat.
There is a $2,500 maximum benefit per Plan Year for special food products for the treatment of an
inherited metabolic disease. The maximum does not apply to coverage of special food products
prescribed or ordered in connection with a mental health diagnosis.
Documentation to substantiate the presence of an inherited metabolic disease, including documentation

that the product purchased is a special food product or enteral formula, may be required before the Plan
will reimburse for costs associated with special food products or enteral formulas.

61

Family Planning, Fertility,
Infertility, Sexual Dysfunction Plan pays 50% of the Maximum
Services and Male Deductible
Deductible
Contraception

Family Planning, Fertility, Infertility, Sexual Dysfunction Services and Male Contraception
Only diagnostic procedures for fertility and infertility are payable for the employee and spouse/domestic
partner. Diagnostic procedures for fertility and infertility are subject to the Plan Year Deductible.
The Plan does not cover the treatment of fertility or infertility. Please see the Benefit Limitations and
Exclusions section, and in particular, the subsections for drugs, medicines, and nutrition; fertility and
infertility; maternity services; and sexual dysfunction services, for more details.
Procedures related to sexual dysfunction may be covered. See the Benefit Limitations and Exclusions section
of this document for more information.
Coverage is provided for vasectomies and tubal ligations. Reversals of prior sterilization procedures,
including, but not limited to tubal ligation and vasectomy reversals are excluded.
Male surgical sterilization is subject to the Plan Year Deductible and Coinsurance.
Male contraception such as condoms are not covered under this Plan.

62

Gender Dysphoria Allowable Charge after Plan Year
Deductible
Deductible
Treatment of Gender Dysphoria
The Plan covers medically necessary treatment of conditions relating to gender dysphoria and gender
incongruence, including medically necessary psychosocial and surgical intervention and any other
medically necessary treatment for such disorders provided by health care practitioners acting within
the scope of their license. Determinations of medical necessity shall include consideration of the most
recent Standards of Care published by the World Professional Association for Transgender Health, or
its successor organization.
If coverage for treatment of a condition relating to gender dysphoria or gender incongruence is
denied on the basis that the requested treatment is not medically necessary, consideration of any
appeal from such denial will include consultation with a provider of health care who has experience
in prescribing or delivering gender-affirming treatment.
The Plan does not cover cosmetic surgery performed by a plastic surgeon or reconstructive surgeon
that is not medically necessary. “Cosmetic surgery” means a surgical procedure that does not
meaningfully promote the proper function of the body, does not prevent or treat illness or disease,
and is primarily directed at improving the appearance of a person.
Procedures, services, and supplies related to surgery and sex hormones associated with gender
affirmation/confirmation should be reviewed by the UM company for medical necessity.

Genetic Counseling/Testing Allowable Charge after Plan Year
Deductible
Deductible
Genetic Testing and Counseling
Certain Genetic Testing and Counseling require precertification. Contact the UM company for
precertification requirements for covered genetic testing.
Benefits include amniocentesis, non-invasive pre-natal testing for fetal aneuploidy, chorionic villus
sampling (CVS), alpha-fetoprotein (AFP), BRCA1 and BRCA2, apo E.
• Amniocentesis, non-invasive pre-natal testing for fetal aneuploidy, chorionic villus sampling (CVS),
and alpha-fetoprotein (AFP) analysis in pregnant women only if the procedure is medically necessary
as determined by the UM company.
• Genetic counseling when provided before and/or after amniocentesis, non-invasive pre-natal testing
for fetal aneuploidy, chorionic villus sampling (CVS), and alpha-fetoprotein (AFP) analysis.
• BRCA1 and BRCA2 counseling for individuals already diagnosed with breast and/or ovarian cancer.
• Apo E genetic test to help physicians identify those individuals at highest risk for heart disease and

63

Genetic Counseling/Testing Allowable Charge after Plan Year
Deductible
Deductible
Genetic Testing and Counseling
determine the most appropriate dietary and fitness program for the covered PEBP participant.
• BRCA1 and BRCA2 genetic test when indicated
o The U.S. Preventive Services Task Force recommends that women with a personal or
family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry
associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutation be assessed
by their primary care physician with an appropriate brief familial risk assessment tool.
Women with a positive result on the risk assessment tool should receive genetic
counseling and, if indicated after counseling, appropriate genetic testing.
This list is not all-inclusive for what genetic tests may be covered. Contact the UM company for coverage
details and precertification requirements for covered genetic testing.
The Plan provides benefits for medically necessary biomarker testing for the diagnosis, treatment,
appropriate management and ongoing monitoring of cancer when such biomarker testing is supported by
medical and scientific evidence.
See the Key Terms and Definitions and the Exclusions sections relating to genetic testing and counseling,
including non-payment for pre-parental genetic testing.

Plan pays 80% after Plan Year Plan pays 50% after Plan Year
Hearing Aids Deductible (maximum benefit Deductible (maximum benefit
$1,500 per device, per each ear) $1,500 per device, per each ear)
Hearing Aids
When air conduction hearing aids are medically necessary, each air conduction hearing aid is subject to the
deductible, then the Plan pays 80% up to a maximum benefit of $1,500 per device, per device, per each ear,
every three years.
Participants may submit a copy of their hearing aid payment receipt from the hearing aid provider to the
third-party claims administrator to request reimbursement for the hearing aid benefit, less applicable
copayment(s), and to receive credit towards the Out-of-Pocket Maximum.
Over the Counter hearing aids are excluded from plan benefits.

64

$0; not subject to Deductible or
Hinge Health Not Covered
Coinsurance
Hinge Health Digital Musculoskeletal (MSK) Care Program
Hinge Health’s Digital MSK Program is offered through the Pharmacy Benefit Manager and is designed
to help members with musculoskeletal care using digital technology. The program offers qualifying
participants virtual physical therapy focusing on prevention, acute injury, chronic and surgical care
programs via digital physical therapy plus additional physical and behavioral support through a full
clinical-care team. Members will also have access to other services, such as pelvic floor therapy,
advanced wearable technology for electrical nerve stimulation and pain relief, expert medical opinion
consultation, health education, etc.
Members will complete a screening questionnaire to assess which Digital MSK Clinic program is right
for them. The questionnaire screener leverages data analytics combined with a dedicated clinical care
team review to match each member’s personal needs with the right program, tools and resources. This
program is managed by Express Scripts and is provided at no cost to members.

Home Health Care and Home Allowable Charge after Plan Year
Deductible; or for infusion drug
Infusion Services Deductible
services 110% of the Medi-Span
AWP after Plan Year Deductible
Home Health Care and Home Infusion Services
• Home Health Care and Home Infusion requires precertification by the UM company.
• Home health care and home infusion services are covered only when ordered by a physician or
health care practitioner.
• Benefits include part-time, intermittent skilled nursing care services and medically necessary
supplies to provide home health care or home infusion services, subject to maximum Plan benefits.
• The maximum Plan benefit for home health care (skilled nursing care services) and supplies to
provide home health care and home infusion services is 60 visits per person per Plan Year. Additional
visits are subject to preauthorization by the UM Company.
• A home health care visit will be considered a periodic visit by a nurse or therapist, or four (4) hours
of home health services.
• Charges are covered for private duty nursing by a licensed nurse (RN or LVN/LPN) only when care is
medically necessary and not custodial in nature. Outpatient private duty nursing care on a 24-hour
shift basis is not covered.
• Outpatient private duty nursing care on a 24-hour shift basis and/or home services other than skilled

65

Home Health Care and Home Allowable Charge after Plan Year
Deductible; or for infusion drug
Infusion Services Deductible
services 110% of the Medi-Span
AWP after Plan Year Deductible
Home Health Care and Home Infusion Services
nursing care are not covered.
• Home services other than skilled nursing care are not covered
• See Benefit Limitations and Exclusions section related to home health care and custodial care,
including personal care and childcare.

Hospice Allowable Charge after Plan Year
Deductible
Deductible
Hospice
The hospice care program administers palliative and supportive health care services providing physical,
psychological, social, and spiritual care for terminally ill patients with a life expectancy of six months or less.
Such services consist of part-time intermittent home health care services totaling fewer than 8 hours per
day and 35 or fewer hours per week. Hospice care of greater than 185 days requires preauthorization by
the UM company.
The Plan also covers outpatient bereavement counseling services provided by a licensed master’s level
clinician or a licensed pastoral care counselor for the patient’s immediate family (covered spouse and or
dependent children) provided as part of the hospice service. Bereavement counseling beyond that included
as a part of the hospice program is payable under the Behavioral Health benefits of this Plan.
For more information, see Hospice Care in the Key Terms and Definitions section.

Hospital Services (Inpatient) Allowable Charge after Plan Year
Deductible
Deductible
Hospital Services (Inpatient)
Elective hospitalization is subject to precertification and concurrent review. See the Utilization
Management section for more information.

66

Hospital Services (Inpatient) Plan pays 80% after Plan Year
Deductible
Deductible
Hospital Services (Inpatient)
• Room and board and facility fees in a semiprivate room with general nursing services; Specialty Care
Units (e.g., intensive care unit, cardiac care unit); lab, x-ray, and diagnostic services; related
medically necessary ancillary services (e.g., prescriptions, supplies).
• Newborn care and circumcision.
• Private room is payable at the semi-private rate unless it is determined that a private room is
medically necessary, or the facility does not provide semi-private rooms.
• Outpatient services with an observation period that lasts more than 23 hours will be considered
and paid as an inpatient confinement under this Plan.
• Under the following circumstances, the Plan will pay for the facility fees and anesthesia associated
with medically necessary dental services if the UM company determines that hospitalization is
medically necessary to safeguard the health of the patient during performance of dental services:
o Dental general anesthesia for an individual when services are rendered in a hospital or
outpatient surgical facility, when the individual is being referred because in the opinion
of the dentist, the individual:
o Is under age 18 and has a physical, mental, or medically compromising condition; or
o Is under age 18 and has dental needs for which local anesthesia is ineffective because
of an acute infection, an anatomic anomaly, or an allergy; or
o Patient has a documented mental or physical impairment requiring general anesthesia
for the safety of the patient.
o Is under age seven (7) and diagnosed with extensive dental decay substantiated by x-
rays and narrative reporting provided by the dentist.
o No payment is extended toward the dentist or the assistant dental provider under this
Plan.
No coverage for non-emergency hospital admission: The Plan does not cover care and treatment billed by
a hospital for a non-medical emergency admission on a Friday or Saturday unless surgery is performed
within 24 hours of the admission.
Inpatient private duty nursing by a licensed nurse (RN, LVN or LPN) is covered only when care is medically
necessary and not custodial, and the hospital’s intensive care unit is filled, or the hospital has no intensive
care unit.

67

Laboratory Outpatient Services
Free-standing lab facility Plan pays 50% of the Maximum
Preferred non-hospital-based Allowable Charge after Plan Year
Deductible
lab facilities: Lab Corp or Quest Deductible
Outpatient hospital-based lab
facility and hospital-based lab
draw station Plan pays 80% after Plan Year
Lab services for pre-admission Deductible
Deductible
testing, urgent care, and
emergency room only
Laboratory Outpatient Services
• Outpatient lab services are covered when medically necessary, when ordered by a physician or
health care practitioner, and when services are performed in accordance with the Laboratory
Outpatient Services benefit described in this section.
Free-standing, non-hospital -based laboratory facility: The Plan covers outpatient routine and
preventive lab services performed at free-standing, non-hospital-based lab facilities. Although there may
be other in-network free-standing, non-hospital-based lab facilities in the network, the Plan’s preferred
facilities include Lab Corp and Quest. Routine and preventive lab services include:
o Medically necessary routine labs when ordered by a physician or other licensed provider acting
within the scope of his/her license as part of comprehensive medical care.
o Preventive laboratory services such as but not limited to basic metabolic panel, lipid panel, etc.
Refer to the Preventive Care/Wellness Services for information regarding benefits for screening
tests and preventive lab testing.
• Outpatient hospital-based lab facilities and hospital-based lab draw stations: The Plan covers
outpatient lab services for pre-admission testing when performed 7 days prior to a scheduled
hospital admission or outpatient surgery. The testing must be related to the sickness or injury for
which admission or surgery is planned.
• If a free-standing, non-hospital-based outpatient laboratory facility is not available within 50 miles
of your residence, you may use a hospital-based laboratory facility or hospital-based draw station.
• See the Key Terms and Definitions section for the definitions of Free-standing Laboratory Facility and
Outpatient Hospital-Based Laboratory and Outpatient Hospital-Based Laboratory Draw Station.

68

Mastectomy and
Reconstructive Services and Plan pays 50% of the Maximum
Breast Reconstruction after Deductible
Deductible
Mastectomy
Reconstruction Services and Breast Reconstruction after Mastectomy
This Plan complies with the Women’s Health and Cancer Rights Act of 1998. Breast reconstructive surgery
and internal or external prosthetic devices are covered for members who have undergone mastectomies
or other treatments for breast cancer. Treatment will be provided in a manner determined in consultation
with the physician and the member. For any covered individual who is receiving mastectomy-related
benefits, coverage will be provided for:
• 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;
• External prostheses that are needed before or during reconstruction; and
• Treatment of physical complications of all stages of the mastectomy, including lymphedema.
Treatment of a leaking breast implant is covered when the breast implant surgery was performed
for reconstructive services following a partial or complete mastectomy.
Prophylactic surgery is covered when prior authorized by the UM company.

Maternity and Newborn Plan pays 50% of the Maximum
Services Deductible
Deductible
Maternity Services
• This Plan covers hospital and birth center charges and professional fees for medically necessary
maternity services.
• Prenatal care and delivery is covered for an employee or spouse/domestic partner only. For covered
dependent children, only prenatal coverage is provided for maternity, except for complications of
pregnancy for the dependent child (see the definition of Complications of Pregnancy in the Key
Terms and Definitions section of this document).
• Some preventive prenatal services including, but not limited to, obstetrical office visits,
breastfeeding support, screening for gestational diabetes, blood type and Rh lab services for spouses
and dependent children may be covered under the preventive care benefit. The preventive benefit
does not include delivery of the newborn(s).

69
• Coverage for newly born and adopted children and children placed for adoption includes coverage
of injury or sickness, including the necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities and, within the limits of the policy, necessary transportation costs
from place of birth to the nearest specialized treatment center under major medical policies, and
with respect to basic policies to the extent such costs are charged by the treatment center.
• Hospital length of stay for childbirth: This Plan complies with federal law that prohibits restricting
benefits for any hospital length of stay in connection with childbirth for the mother or newborn child
to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean
section, or requiring a health care practitioner to obtain authorization from the Plan or its UM
Company for prescribing a length of stay not more than those periods. However, federal law
generally does not prohibit the mother’s or newborn’s attending health care practitioner, after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or
96 hours, if applicable).
• Elective termination of pregnancy is covered only when the attending physician certifies that the
mother’s health would be endangered if the fetus were carried to term. Termination of pregnancy -
See the Genetic Testing section of this Schedule of Benefits.
• See Breastfeeding Support section for information and benefits related to this type of service. See
the exclusions related to Maternity Services in the Exclusions section.
• See the Enrollment and Eligibility Master Plan Document for information regarding how to enroll a
newborn dependent child(ren).
When the member has Employee-Only coverage, the newborn will be covered under the member’s plan
for the first 31 days, consistent with NRS 689B.033. Individual deductible, copay, coinsurance, and out
of pocket limitations, where applicable, will apply during the initial coverage period.

Plan pays 80% after Plan Year Allowable Charge or 110% of the
Nondurable Supplies
Deductible Medi-Span AWP after Plan Year
Deductible
Nondurable Supplies
Coverage is provided for up to a 31-day supply per month of:
• Sterile surgical supplies used immediately after surgery;
• Supplies needed to operate, or use covered durable medical equipment or corrective appliances;
and
• Supplies needed for use by skilled home health or home infusion personnel, but only during their
required services.
Please see the Participant Contact Guide for information regarding the preferred diabetic supplies mail
order program.
Diabetic supplies may also be covered under the prescription drug benefit, see the section on Prescription

70
Drug Benefits in this document for more information.
Obesity Care Disease Management Program (Enhanced Benefits)

Plan pays 100%; not subject to
Office Visits Allowable Charge after
Deductible
Deductible
Laboratory Test (must be
performed using a free- Plan pays 100%; not subject to
Allowable Charge after
standing, non-hospital-based Deductible
Deductible
laboratory)
Plan pays 100%; not subject to
Nutritional Counseling Services Allowable Charge after
Deductible
Deductible
Smart90 Retail
Preferred Retail or ESI Home
Weight loss medications
30-Day Supply Delivery
90-Day Supply
Preferred Generic *$5 Copay $15 Copay Not covered
Preferred Brand *$25 Copay, *$75 Copay, Not covered
Non-Preferred Brand Not covered Not covered
Preferred Retail Network Pharmacies: Copayments apply if you fill your prescription at an Express
Advantage Network (EAN) retail pharmacy. If you fill your prescription at a non-EAN retail pharmacy, you
will pay an additional $10 per prescription. If you currently use a non-EAN pharmacy and you want to
avoid the $10 upcharge, call an EAN pharmacy to transfer your prescription. Certain weight loss
medications may not be available in 90-day supply. Contact Express-Scripts for information about your
prescribed medication.
The Obesity Care Management (OCM) Program is a disease management program that provides enhanced
benefits to participants who have been diagnosed as obese by their physician, who meet the criteria in
this section, and have enrolled in the OCM Program.
The OCM Program is a voluntary opt-in program that requires enrollment with the third-party claims
administrator to determine if you meet the criteria for participation in the program. If the third-party

71
claims administrator determines you to be eligible for the program, the effective date of enrollment and
enhanced benefits is determined by the third-party claims administrator.
How to enroll in the OCM Program:
• Contact the third-party claims administrator for a list of In-Network weight loss providers. The list of
In-Network weight loss providers and the OCM Enrollment and Evaluation Form may be obtained by
logging into the E-PEBP Portal at https://pebp.nv.gov/ and selecting UMR.
• Schedule an appointment with a provider from the list of participating In-Network weight loss
providers.
• Attend your scheduled appointment and have your provider complete, sign and submit the
Enrollment and Evaluation Form to the third-party claims administrator’s address or fax number
provided on the form.
• The third-party claims administrator will review the information submitted by your provider and if
the information indicates that you meet the criteria for the weight loss program benefits, the third-
party claims administrator will enroll you in the program and notify the Pharmacy Benefit Manager
of your enrollment.
• If you do not meet the criteria for the weight loss program and enhanced benefits, the third-party
claims administrator will notify of the denial of the OCM Program’s enhanced benefits.
OCM Program participation criteria for adults 18 years and older and services must be provided by:
• An In-Network provider who specializes in weight loss services;
• An In-Network provider who is certified by the American Board of Bariatric Medicine (ABBM);
• An In-Network provider who is in training to become certified by the American Board of Bariatric
Medicine (ABBM); or
• If no provider as described above is available within 50 miles of a participant’s residence, then any
In-Network provider.
The patient’s BMI must be greater than 30 kg/m2, with or without any co-morbid conditions present, or
greater than 25 kg/m2 (or waist circumference greater than 35 inches in women, 40 inches in men) if one
or more of the following co-morbid conditions are present:
• Coronary artery disease.
• Diabetes mellitus type 2.
• Hypertension (Systolic Blood Pressure greater than or equal to 140 mm Hg or Diastolic Blood
Pressure greater than or equal to 90 mm Hg on more than one occasion).
• Obesity-hypoventilation syndrome.
• Obstructive sleep apnea.
• Cholesterol and fat levels measured (Dyslipidemia):
• HDL cholesterol less than 35 mg/dL.
• LDL cholesterol greater than or equal to 160 mg/dL; or
• Serum triglyceride levels greater than or equal to 400 mg/dL.
For children ages two to 18 years:

72
• All the above criteria.

• Services must be provided by an In-Network provider who specializes in childhood obesity; and
• Child must present a BMI ≥ 85th percentile for age and gender.
Engagement in the OCM Program:
In addition to meeting the criteria above, you must remain actively engaged by complying with the
treatment plan established by you and weight loss provider.
Monitoring Engagement in the OCM Program:
Your OCM provider must submit monthly reports to include your weight loss (weight, BMI, and waist
circumference) and your compliance with the treatment plan. Submission of these reports will be a
requirement for payment under the OCM Program’s enhanced benefits. If your monthly weight loss
reports are not received by the third-party claim’s administrator, your benefits under this program will
end, and your coverage will return to the standard CDHP benefits where other Plan limitations will apply.
The effective date of the return to the standard CDHP benefits will be the first day of the month following
the non-compliance notification received from the third-party claim’s administrator.
You and your weight loss provider will determine your final weight loss goal when you initially start
participating in the OCM Program. Once you have met your final weight loss goal, the OCM Program’s
enhanced benefits will return to the standard CDHP benefits on the first day of the following month. The
OCM Program does not provide enhanced benefits for ongoing maintenance care. Ongoing maintenance
care will be subject to the standard CDHP benefits.
Laboratory Services:
Routine wellness laboratory testing must be performed at an In-Network free-standing laboratory facility,
for example Lab Corp or Quest. A hospital-based outpatient laboratory/draw station is not a free-standing
laboratory.
Nutritional Counseling Services:

The frequency of nutritional counseling services will be determined by the claims administrator and based
on your weight loss provider’s recommendation and medical necessity.
Weight Loss Medications:

• The Plan covers certain only short-term use obesity/weight loss generic medications as identified by
the Plan’s pharmacy benefits manager. Contact the pharmacy benefit manager or refer to the Plan’s
prescription drug formulary to determine what weight loss medications are covered by the
enhanced benefit.
• Copayment for a 31-90-day supply is subject to three times the listed 30-day retail copayment.
• This Plan does not coordinate prescription drug plan benefits.
• Medications purchased at non-participating pharmacies are not covered under this Plan.
Other limitations:

73
• Weight loss medications: Preferred Retail Network Pharmacies, Smart90 Retail, and Express Scripts
Home Delivery Program requirements apply. Refer to the Schedule of Prescription Drug Benefits for
coverage limitations, cost implications and details regarding these programs.
The Obesity Care Management Program is administrated by the Claims Administrator.

Oral Surgery, Dental Services, Plan pays 80% after Plan Year Plan pays 50% of the Maximum
and Temporomandibular Joint Deductible Allowable Charge after Deductible
Disorder
*TMJ related services: Plan pays Plan pays 50% of the Maximum
Injury to teeth; Oral and or
80% after Plan Year Deductible Allowable Charge after Deductible
craniofacial surgery.
Oral and Craniofacial Services
• Expenses for dental services may be covered under the medical plan if the expenses are incurred for
the repair or replacement of injury to teeth or restoration of the jaw if damaged by an external
object in an accident. For the purposes of this coverage by the medical Plan, an accident does not
include any injury caused by biting or chewing.
o Treatment of injury to teeth must be provided by a dentist or physician and is limited to
restoration of teeth to a functional level, as determined by the Plan Administrator or its
designee.
• Coverage for dental services as the result of an injury to teeth will be extended under the medical
plan to a maximum of two years following the date of injury, regardless of date enrolled in the plan.
Restorations past the two-year time frame may be considered under the dental benefits described
in the PEBP Self-funded Dental PPO Plan Master Plan Document available at https://pebp.nv.gov/.
• Certain oral or craniofacial surgery is required to be prior authorized by the utilization management
company. See the UM section of this document or refer to Participant Contact Guide.
• Oral or craniofacial surgery is limited to surgical procedures to remove tumors, cysts, abscess
including dental abscess and cellulitis, or for acute injury.
• Frenectomy based on medical necessity as determined by the UM company.
• *Temporomandibular Joint (TMJ) services are payable under the medical Plan when medically
necessary but not if treatment is recognized as a dental procedure, involves extraction of teeth or
application of orthodontic devices (e.g., braces) or splints.
For additional information, see the Exclusions section related to dental services.

74

Plan pays 80% after Plan Year Plan pays 50% of the Maximum
Outpatient Surgery Facility
Deductible Allowable Charge after Deductible
Outpatient Surgery Facility
• See the UM section for precertification requirements.
• Outpatient ambulatory surgical facility/surgical center.
• Physician fees payable under the physician services section of this Schedule of Benefits.
• Outpatient surgery with an observation period that lasts more than 23 hours will be considered
and paid as an Inpatient confinement under this medical Plan.
• Outpatient facility fees and anesthesia associated with medical necessary dental services for an
individual when the individual is being referred by the dentist, and the following criteria are met:
o Is under age 18 and has a physical, mental, or medically compromising condition; or
o Is under age 18 and has dental needs for which local anesthesia is ineffective because of an acute
infection, an anatomic anomaly, or an allergy; or patient has a documented mental or physical
impairment requiring general anesthesia for the safety of the patient; or is under age seven (7)
and diagnosed with extensive dental decay substantiated by x-rays and narrative reporting
provided by the dentist.
• No payment is extended toward the dentist or the assistant dental provider fees under this medical
Plan. Refer to the dental benefits described in the PEBP Self-funded PPO Dental Plan Master Plan
Document available at https://pebp.nv.gov/.

Physician and Other Health Plan pays 80% after Plan Year
Care Practitioner Services Deductible
Deductible
Physician and Other Health Care Practitioner Services
This benefit includes physician and health care practitioner’s fees for services provided in a hospital,
emergency room, urgent care center, a health care practitioner’s office or at home. Physician and health
care practitioners include licensed providers acting within the scope of their license, such as but are not
limited to the following:
• Surgeon
• Assistant surgeon (if medically necessary)
• Anesthesia by physicians and Certified Registered Nurse Anesthetists (CRNA)
• Pathologist; Radiologist
• Physician Assistant; Nurse Practitioner; Nurse Midwife
• Homeopathic Physicians, Christian Science Practitioners, Oriental Medicine Doctor (OMD)
only for Acupuncture
• Podiatrist
• Psychologist, Psychiatrist, Licensed Clinical Social Worker

75

Physician and Other Health Plan pays 80% after Plan Year
Care Practitioner Services Deductible
Deductible
Physician and Other Health Care Practitioner Services
The Plan Administrator or its designee will determine if multiple surgical or other medical procedures will
be covered as separate procedures or as a single procedure based on the factors in the definition of
“Surgery/Surgeries” in the Key Terms and Definitions section.
Assistant surgeon fees will be reimbursed for medically necessary services to a maximum of 20% of the
eligible expenses payable to the primary surgeon. A Certified Surgical Assistant (see Key Terms and
Definitions section) is payable as an assistant surgeon.
Podiatry benefits include routine foot care for the treatment of foot problems such as bunions, corns,
calluses, and toenails are covered only for individuals with a metabolic disorder such as diabetes, or a
neurological or peripheral-vascular insufficiency affecting the feet.
No coverage is provided for prophylactic surgery or treatment as defined in the Key Terms and Definitions
section and as explained in the Exclusions section, unless otherwise specified in this document.
No coverage for homeopathic treatments, supplies, remedies, or substances.

Preventive Care/Wellness Plan pays 100%, not subject to
Not Covered
Benefits Deductible
Colorectal Cancer Screening
Plan pays 100%, not subject to
(Colonoscopy/bowel prep or Not Covered
Deductible
Cologuard)
Women’s Preventive Services
Well-woman visits; screening for
gestational diabetes; human
Plan pays 100%, not subject to
papillomavirus testing; Not Covered
Deductible
counseling/screening: human immune
deficiency virus, mammograms,
interpersonal and domestic violence
BRCA Risk Assessment and Genetic Plan pays 100%; not subject to
Not Covered
Counseling/Testing Deductible
• BRCA risk assessment for women with a personal or family history of breast, ovarian, tubal, or peritoneal
cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene
mutations.
• Genetic Counseling following a positive result on risk assessment and, if indicated after counseling, genetic
testing.
• BRCA testing requires precertification.

76

Not Covered
Benefits Deductible
Plan pays 100%, Not subject to
Breastfeeding Support/Equipment Allowable Charge after
Deductible
Deductible
Coverage for comprehensive lactation support and counseling from trained providers for women during the
prenatal and postpartum period and up to one year following delivery. Coverage for breastfeeding equipment
and supplies in conjunction with each live birth. The Plan covers one manual or standard electric breast pump
per live birth.
Contact the third-party claims administrator regarding the purchase of covered breast pumps. Rental for heavy
duty electrical (hospital grade) breast pump covered only when the UM company determines it is medically
necessary and only during the newborn’s inpatient hospital stay.
Contraceptives / Family Planning Plan pays 100%, not subject to Allowable Charge after
Deductible Deductible; pharmacy not
covered
• Up to 12-month supply, per prescription, of a drug for contraception or its therapeutic equivalent;
• Devices for contraception, and insertion and removal of such devices;
• Self-administered hormonal contraceptives;
• Education and counseling relating to the initiation of the use of contraception and any necessary follow-up;
• Management of side effects of contraception; and
• Voluntary sterilization for women.
Includes contraceptive injection or the insertion of contraceptive device at a hospital immediately after an insured
gives birth.
Methods of covered contraception:
• Elective sterilization for • Combined estrogen- • Vaginal • Combined estrogen-

women and progestin-based contraceptive rings and progestin-based
• Surgical sterilization drugs • Diaphragms drugs for emergency
implants for women • Progestin-based w/spermicide contraception or
• Implantable rods drugs • Sponges w/spermicide progestin-based
• Copper-based • Extended- or • Cervical caps drugs for emergency
intrauterine devices continuous-regimen w/spermicide contraception
• Progesterone-based drugs • Female condoms • Ulipristal acetate for
intrauterine devices • Estrogen- and • Spermicide emergency
• Injections • progestin-based
Female condoms contraception
patches
• Spermicide

Preventive Care/Wellness Benefits

77

Not Covered
Benefits Deductible
This Plan complies with the Patient Protection and Affordable Care Act; IRS rules and regulations for
HSAs, and in particular, Section 223 of the Internal Revenue Code; and applicable Nevada law
regarding covered preventive care.
Recommended preventive care services are covered with no cost sharing when provided by in-
network providers. Preventive care services are not subject to and will not apply to the Plan Year
Deductible or Out-of-Pocket Maximum. Some preventive care services have service quantity
limitations.
Preventive care focuses on detecting and preventing medical problems before they become more
serious. Preventive care services include:
• Recommendations of the U.S. Preventive Services Task Force with a current rating of “A” or “B,”
including:
o Screening for various conditions, including depression, diabetes, obesity, hypertension,
sexually transmitted infections, prenatal conditions, and various cancers;
o Medications intended to prevent conditions, including those intended to prevent HIV,
breast cancer, and heart disease; and
o Counseling for various medical concerns, including addressing drug use, tobacco use,
healthy diet, and physical activity.
• Immunizations recommended by the federal Advisory Committee on Immunization Practices
(ACIP), including influenza, COVID-19, hepatitis A, hepatitis B, HPV, measles/mumps/rubella,
meningitis, RSV, shingles, and Tdap.
• Recommendations by the Women’s Preventive Services Initiative, including well-woman visits,
pelvic examinations, Pap smears, breast exams, and prenatal visits.
• Recommendations by the Health Resources and Services Administration’s with respect to the
health of infants, children, and adolescents, including well-child visits, behavioral and
developmental assessments, and screening for autism, certain genetic diseases, lipid disorders,
tuberculosis, and vision impairment.
• Annual check-ups, including related screening lab and x-rays.
o Please note: routine lab services from independent labs may not be recognized as
preventive care unless there is a corresponding wellness office visit within a reasonable
number of days prior to or after lab date
Your physician may recommend a preventive service that is not listed in this document. For additional
information regarding preventive benefit information, contact the third-party claims administrator listed
in the Participant Contact Guide.
Guidelines for common preventive services:

78

Not Covered
Benefits Deductible
Mammogram: The first preventive mammogram of the Plan Year is covered at 100% for women aged 40
years and older or beginning at age 35 for members with a high-risk of breast cancer, when performed in-
network.
Colorectal cancer screening: Once every 10 years for adults aged 45 years and older who are at average
risk of colorectal cancer, or beginning at age 40 for members with a high-risk of colorectal cancer.
Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk
Factors: Behavioral Counseling Interventions for adults aged 18 years and older are covered under the
Wellness/Preventive Benefit when referred by a primary care practitioner for those who have a basal
metabolic index (BMI) of 30 or greater and have additional cardiovascular disease (CVD) risk factors. This
wellness/preventive benefit is limited to twelve (12) Healthy Diet/Physical Activity Counseling or Obesity
Screening/Counseling visits per Plan Year. Additional visits are subject to a specialist visit copay,
deductible, or coinsurance where applicable.
Smoking/Tobacco Cessation:
• Prescription and over-the-counter smoking/tobacco cessation products are covered under the
prescription drug program. Over-the-counter smoking cessation products must be accompanied
by a prescription written by a physician.
• Some examples of cessation products eligible to be paid at 100% include Chantix (by
prescription only), nicotine gum, nicotine patches, and nicotine lozenges.
Some limitations on quantity may apply and are at the discretion of the Pharmacy Benefit
Manager and your physician.
• Benefits for over-the-counter products are limited to those that are FDA-approved and
recommended by the Surgeon General.
• Over-the-counter smoking/tobacco cessation products may be obtained by presenting your
physician’s written prescription to an in-network pharmacy, or you can submit your purchase
receipt for the product with your physician’s written prescription attached to the Prescription Drug
Reimbursement Claim Form (this form is located at https://pebp.nv.gov/).
• Second-line therapies such as clonidine hydrochloride and nortriptyline hydrochloride are
sometimes used in the management of smoking/tobacco-cessation; however, due to the lack of an
FDA-approved indication for smoking cessation, as well as undesirable side effect profiles, currently
prohibit these agents from achieving first-line classification and therefore, not covered under the
Preventive Care/Wellness Services Benefit.
• The Plan does not cover electronic cigarettes.
For more information, please visit or contact the third-party claims administrator.
Helpful Resources
For more information on recommendations issued by medical and scientific bodies that affect what is
considered preventive care, please see their websites:

79

Not Covered
Benefits Deductible
U.S. Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/uspstf/
Advisory Committee on Immunization Practices: https://www.cdc.gov/vaccines/acip/index.html
Women’s Preventive Services Initiative: https://www.womenspreventivehealth.org/recommendations/
Health Resources & Services Administration, Bright Futures: https://mchb.hrsa.gov/programs-

impact/bright-futures

Radiology & Radiation Therapy Allowable Charge after Plan Year
Deductible
Deductible
Radiation Therapy, including Radiology (X-Ray), Nuclear Medicine & Radiation Therapy
Services (Outpatient)
Radiology
The Plan covers medically necessary specialty radiology when ordered by a physician or health care
practitioner acting with the scope of their license, including MRI, MRA, MRS MRT, PET, SPEC, and CT
scan. Precertification required for CT, MRI, SPECT and PET. For other precertification requirements, see
the Utilization Management (Prior Authorization) section.
The Plan covers technical and professional fees associated with outpatient radiology tests
performed 7 days prior to a scheduled hospital admission or outpatient surgery. The testing must
be related to the sickness or injury for which admission or surgery is planned.
Refer to the Preventive Care/Wellness Services section of this document for information
regarding benefits for screening radiology services and other preventive radiology testing.
Radiation Therapy
Medically necessary professional services related to radiation therapy are covered.

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Real Appeal No cost to Participants Not Covered

Real Appeal provides eligible members who are at least 18 years old a benefit for virtual weight loss
and weight management coaching sessions, with no cost to the member.
This support includes one-on-one coaching and online group sessions with supporting video content
delivered by a virtual coach.
A qualified enrolled member will receive:

• Access to a coach who will guide you through the program and develop a custom plan
that fits your needs, preferences, and goals;
• 24/7 access to digital tools and dashboards;
• A Real Appeal kit containing health weight management tools that may include fitness
guides, recipes, digital food and weight scales; and
• Support from online group classes with a coach and other members who share what has
helped them achieve success.
For more information, contact the Plan’s third-party claims administrator listed in the Participant
Contact Guide.

Rehabilitation Services (Cardiac, Inpatient or Outpatient: Plan Plan pays 50% of the Maximum
Physical, Occupational, and pays 80% Allowable Charge after Plan Year
Speech Therapy) after Plan Year Deductible Deductible
Rehabilitation Services (Physical, Occupational, and Speech Therapy)
• Rehabilitation services are covered only when ordered by a physician or other provider acting
within the scope of their license.
• Inpatient rehabilitation admission requires prior authorization.
• Prior authorization for outpatient rehabilitative and habilitative therapy (occupational, physical, or
speech) exceeding 90 combined visits per Plan Year. Visit limits will not apply to Medically
Necessary treatment of mental health or substance use disorder.
• There is no limit for Cardiac Rehabilitation services.
• Benefits for rehabilitation therapy are limited to services given for acute or recently acquired
conditions that, in the judgement of the member’s physician, are subject to significant
improvement through short-term therapy.

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Rehabilitation Services (Cardiac, Inpatient or Outpatient: Plan Plan pays 50% of the Maximum
Physical, Occupational, and pays 80% Allowable Charge after Plan Year
Speech Therapy) after Plan Year Deductible Deductible
Rehabilitation Services (Physical, Occupational, and Speech Therapy)
• Short term active, progressive rehabilitation services for occupational, physical, or speech
therapy must be performed by a licensed or duly qualified therapist/provider acting within the
scope of their license.
• Inpatient rehabilitation services in an acute hospital, rehabilitation unit or facility or skilled
nursing facility for short term, active, progressive rehabilitation services that cannot be provided
in an outpatient or home setting.
• Maintenance Rehabilitation and coma stimulation services are not covered (see specific
exclusions relating to rehabilitation therapies in the Exclusions section).
• Speech therapy is covered if the services are provided by a licensed or duly qualified speech
therapist to restore normal speech or to correct dysphagia, swallowing defects, to correct speech
disorders due to childhood developmental delays and disorders due to illness, injury, or a surgical
procedure. Speech therapy is payable following surgery to correct a congenital condition of the
oral cavity, throat, or nasal complex (other than a frenectomy), an injury, or sickness that is other
than a learning disorder.
See the see the Utilization Management section for prior authorization requirements.

Second Physician Opinion Plan pays 50% of the Maximum
Includes only one office visit per Allowable Charge after Plan Year
Deductible
opinion Deductible
Second Physician Opinion
For your second opinion, you may choose any In-Network, Board-certified specialist who is not an
associate of the attending physician.
2nd.MD is PEBP’s preferred second opinion service. See benefits in the Schedule of Benefits, below, for
additional information.

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2nd.MD (Second Opinion Plan Pays 100%, not subject to Not Covered
Service) Deductible
Listed prices are before
Telemedicine deductible has been met. The Not Covered
Doctor on Demand (DoD) only plan pays 80% after Plan Year
Deductible is met.
Medical Visit $49 Not Covered
Psychology Visit (25-minute visit) $79 Not Covered
Psychology Visit (50-minute visit) $129 Not Covered

Psychiatry Visit (initial 45-minute
$229 Not Covered
visit)
Psychiatry Visit (15-minute follow-
$99 Not Covered
up visit)
Telehealth (other telemedicine Plan pays 50% of the Maximum
providers) Deductible
Deductible
Telemedicine and Telehealth
• Doctor on Demand telemedicine services is PEBP’s contracted telehealth provider and are
considered In-Network. To learn more, visit http://www.doctorondemand.com/pebp.
• 2nd.MD provides eligible members with direct access to elite specialists across the county for
expert second opinions. Specialists answer questions about disease, cancer, chronic conditions,
surgery or procedure, medications, and treatment plans. Specialists are board certified, leaders in
research, and pioneers in medicine. To learn more visit www.2nd.MD/PEBP or call 1-866-841-
2575.
• Alternatively, telemedicine may be available from in-network providers and is covered on the
same basis as in-person services. It is your responsibility to ensure the providers you use are
in-network providers. Failure to use in-network providers will result in a denial of benefits and
higher cost to you.

Skilled Nursing Facility (SNF) Plan pays 50% of the Maximum
and Subacute Care Facility Deductible
Deductible
Skilled Nursing Facility (SNF) and Subacute Care Facility
• Admission to a skilled nursing facility or subacute care facility must be ordered by a physician and
requires prior authorization (see the Utilization Management section of this document).

83

Skilled Nursing Facility (SNF) Plan pays 50% of the Maximum
and Subacute Care Facility Deductible
Deductible
• Skilled nursing facility (SNF) confinement or subacute care facility confinement payable up to 60 days
per Plan Year for confinements related to the same cause. Additional visits are subject to
preauthorization by the UM Company.
Benefit Description Center of Excellence Non-Center of Excellence

Transplant Services (Organ and Plan pays 80% after Plan Year Plan pays 50% of the Maximum
Deductible Allowable Charge after Plan Year
Tissue)
Deductible
Transplants (Organ and Tissue)
• Coverage is provided only for eligible services related to non-experimental transplants of human
organs or tissue, along with the facility and professional services, FDA-approved drugs, and medically
necessary equipment and supplies.
• Coverage is provided for the donor when the receiver is a participant under this Plan. Coverage is
provided for organ or tissue procurement and acquisition fees, including surgery, storage, and organ
or tissue transport costs related to a living or nonliving donor (transport within the U.S. or Canada
only). When the donor has medical coverage, his or her plan will pay first and the benefit under this
Plan will be reduced by the amount payable by the donor’s plan.
• Expenses incurred by a participant of this Plan who donates an organ or tissue are not covered unless
the person who receives the donated organ/tissue is also a participant covered by this Plan.
• Transplantation-related services require precertification (see the Utilization Management section of
this document for details). Coverage is provided only for eligible services related to non-experimental
transplants of human organs or tissue, along with the facility and professional services, FDA-approved
drugs, and medically necessary equipment and supplies.
• See the Exclusions section related to experimental and investigational services and transplants.
• To receive maximum Plan benefits, members must use a Center of Excellence for single organ or
combined organs and tissue transplants. Transplant Center of Excellence facilities will be identified by
the claim’s administrator. For information regarding transplant benefits and Centers of Excellence
facilities, contact the third-party claims administrator at 888-763-8232.
• This Plan provides for reimbursement of certain costs associated with travel and lodging
accommodations for the patient and one additional person (spouse/domestic partner, family member
or friend) when associated with medical treatment for organ and tissue transplants performed at a
Center of Excellence. For travel expense benefits, refer to the Travel Expenses section.
• Expenses incurred for travel and lodging accommodations for organ and/or tissue transplants not
performed at a Center of Excellence are not covered.
• PEBP does not provide advance payment for travel expenses related to organ or tissue transplants.

84
Benefit Description
Travel Expenses Not Subject to Deductible and Out-of-Pocket Maximum

Travel Expenses
This Plan allows for the reimbursement of certain travel and lodging accommodation expenses
consistent with Section 213(d) of the Internal Revenue Code and IRS Publication 502 for qualified
medical expenses for the member and one additional person (travel companion).
Travel expenses are covered when incurred in conjunction with the member’s:
• Transplant or bariatric surgery.
o This includes pre-surgery appointments such as evaluations, testing, counseling, etc.
• Hip and knee total joint replacement surgery performed at an approved exclusive Nevada
hospital/ ambulatory surgery facility when prior authorized by the utilization management
company
o This includes pre-surgery evaluations, and
o For one year after surgery for follow-up visits as required by the patient’s surgeon; and
• Travel expenses related to an organ or tissue transplant or bariatric surgery scheduled or
performed at a facility or other provider type that is not a Center of Excellence as determined
by the Plan Administrator or its designee will not be covered.
o Travel expenses related to an inpatient or outpatient surgery that is not determined to be
a preferred hospital/ambulatory surgical facility by the UM company will not be covered.
There are no exceptions.
• Travel for a participant located in a State with more restrictive access to abortion than Nevada,
see NRS 422.250, to the nearest care center for abortion services covered under this Plan.
The plan reimburses for travel up to one year after services for follow-up visits as required by the
patient’s provider/surgeon. Travel expenses incurred on or after one year are not eligible for
reimbursement.
If the travel companion has their own separate PEBP plan, travel expense reimbursement will not
apply to the companion.
PEBP does not provide advance payment for travel expenses.
The Plan will reimburse up to the GSA rate for lodging, travel, meals, or actual expenses, whichever is
less.
Pre-approval for travel expenses:

• Travel expenses must be pre-approved by PEBP or its designee

85
Benefit Description

Travel Expenses
o If the member is unable to obtain pre-approval because the organ or tissue transplant
required immediate travel, the member may submit travel costs to PEBP or its designee
after the transplant surgery.
Pre-approval will provide an estimation of your travel reimbursement based on GSA rates. A Travel
Pre-Authorization form is available at pebp.nv.gov.
Submitting Travel Reimbursement form and receipts:

• Requests for travel expense reimbursement must be submitted to PEBP using the Travel
Reimbursement form available at pebp.nv.gov.
• Travel Reimbursement forms and receipts must be submitted within 12 months of the date of
the service.
o The form must be completed, including the start and end times, destination, and purpose
of trip
o Must include original itemized receipts identifying the name(s) of the person(s) incurring
the expense. If the travel includes a commercial airline flight, an itinerary attached for meal
justification.
Reimbursement of eligible travel expenses, including any relating to a travel companion, will be
payable to the primary participant.
Reimbursement will be based on actual expenses incurred and the actual number of days and travel
times and may differ from the pre-approval estimation. The lessor of GSA rates or actual expenses
will be used.
Meals will be reimbursed in accordance with the meals and incidental expense (M&IE) allowance.
Receipts are not required for the M&IE allowance. Participants should refer to the GSA’s website
http://gsa.gov and the link “Per Diem Rates” for the most current rates.
Eligible Travel Expenses include:

This Plan follows the travel expense reimbursement guidelines established in Section 213(d) of the
Internal Revenue Code, IRS Publication 502, and under the GSA rates based on region or locality.
• Method of transportation including personal car, airline, rental car, bus, taxi, etc. The least
expensive method of transportation must be used.
o Flight expenses for commercial air (regular coach rate).
o Mileage reimbursement for personal vehicle (GSA non-medical mileage rate).
• Travel meals (for patient and travel companion only).

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Benefit Description

Travel Expenses
o Reimbursement for meals while traveling will apply the GSA rate for the travel day for
the first and last day of travel.
• Lodging accommodations (GSA rate)
o For transplants, some Centers of Excellence facilities may have on-site or affiliated
lodging services.
▪ For required lodging, the plan will pay the lesser of the affiliated lodging or GSA
rates, subject to verification of availability.
Travel expenses are not subject to cost-share (Deductible, copay, and/or Out-of-Pocket Maximum).
Therefore, PEBP will issue appropriate reporting forms (form 1099, W2, etc.) for federal tax reporting
purposes. You may be liable for taxes and must consult your tax professional for further assistance.
Excluded travel expenses:

The following are specifically excluded from reimbursement under any circumstances (other
expenses not included below may be denied if they are not preapproved):
• Alcoholic beverages.
• Car maintenance.
• Vehicle insurance.
• Flight insurance.
• Cards, stationery, stamps.
• Clothing.
• Dry cleaning.
• Entertainment (cable televisions, books, magazines, movie rentals).
• Flowers.
• Household products.
• Household utilities, including cell phone charges, house cleaner, baby-sitter, or day care
services.
• Kennel fees.
• Laundry services.
• Security deposits.
• Toiletries.
• Travel expenses related to a facility or provider that is not a certified Center of Excellence,
exclusive hospital/ambulatory surgical facility, or outpatient infusion facility; and
• Travel expenses incurred on or after one year following services are not eligible for
reimbursement.

87

Vision Screening Exam Plan pays 80% after Plan Year Plan pays 80% of the Maximum
Deductible Allowable Charge after Plan Year
(Preventive)
Deductible
Vision Screening Exam*
• One annual preventive vision screening exam including refractive error testing per Plan Year.
• Hardware such as but not limited to contact lenses, lenses and frames are not covered.
• *When refraction is conducted in conjunction with an examination with a medical diagnosis,
such as cataracts, it will be paid under the medical benefit, subject to Deductible and
Coinsurance.
• PEBP does not maintain a network specific to vision care; however, the PPO network does have
a list of some vision providers.

88
Schedule of Prescription Drug Benefits

Benefits for prescription drugs are provided through the prescription drug plan administered by
the Pharmacy Benefit Manager, Express Scripts (ESI). Coverage is provided only for those
pharmaceuticals (drugs and medicines) obtained from In-Network providers and approved by the
U.S. Food and Drug Administration (FDA) as requiring a prescription and FDA approval for the
condition, dose, route, duration, and frequency, if prescribed by a physician or other practitioner.
The following schedule includes explanations and limitations that apply to each benefit; however,
the explanations and limitations may not include every limitation. For more information relating
to a specific benefit, refer to Utilization Management (for any precertification requirements),
Benefit Limitations and Exclusions, Key Terms and Definitions and other sections that may apply
to a specific benefit.
For helpful tools such as “Price a Medication” see the Participant Contact Guide section or go to
the PEBP website at https://pebp.nv.gov/.
Prescription Drug Benefits
Preferred/Formulary Generic Plan pays 80% after Plan Year

Drugs Not Covered
Deductible
Preferred/Formulary Brand Drugs Plan pays 80% after Plan Year

Not Covered
Deductible
You pay 100% of the cost of the
Non-Preferred/Non-Formulary medication; Deductible and Out-
Brand Drugs Not Covered
of-Pocket Maximum credit is not
applied
Specialty Pharmaceutical Drug Deductible; for drugs not on the
(Accredo Specialty Pharmacy) Not Covered
SaveOnSP program, there is
$100 min/$250 max copay
ACA Mandated Preventive Drugs:
Preventive Medications Plan Pays 100%, not subject to
(Limited only to those preventive Plan year Deductible
Not Covered
drugs identified by the pharmacy Other Preventive Drugs: Plan pays
benefit manager) 80%, not subject to Plan Year
Deductible

89
Prescription Drug Benefit

This Plan does not coordinate prescription drug plan benefits.
Some over the counter (OTC) drugs and prescription drugs are eligible to be covered under the Plan’s
Preventive Care/Wellness Services benefit in accordance with the Affordable Care Act; whereby, the Plan
will waive the Copays and Deductibles and products are paid at 100%. Please contact Express Scripts for
more information.
Certain OTC female contraception products are covered when presented with a prescription from your
physician to your pharmacy. These types of products include the female condom, sponges, and
spermicides. Refer to the “Contraceptives/Family Planning” portion of the Preventive Care/Wellness
Benefits section or contact Express Scripts for more information. The plan adheres to NRS 695G.1715
regarding drugs for contraception or its therapeutic equivalent.
Many vaccines may also be administered through the prescription drug benefit with certain pharmacies.
Contact Express Scripts or visit www.express-scripts.com to check vaccine coverage and locate your
nearest In-Network pharmacy. Contact the pharmacy to verify their current vaccination schedule and
vaccine availability.
Coverage is also provided for, but not limited to:

• Vaccinations such as shingles, HPV, Flu, pneumonia, Herpes Zoster, TDAP (whooping cough)
• Prenatal & pediatric prescription vitamins
• Prescription female oral contraceptives
• Insulin, diabetic supplies (such as lancets, syringes, test strips), insulin pumps, and
insulin pump supplies.
o Insulin pumps and supplies are covered under the pharmacy benefit’s base day and
quantity limits, subject to copayments, deductibles, or coinsurance.
• Orally Administered Chemotherapy: The Copayment, after deductible, or Coinsurance
amount for orally administered chemotherapy drugs will be consistent with the drug’s
formulary tier for retail, home delivery and Specialty pharmacy; and in accordance with NRS
695G.167, the cost will not exceed $100 per prescription for a 30-day supply.
• Prescription drugs irregularly dispensed for purposes of synchronization of chronic
medication pursuant to the provisions of NRS 695G.1665
• Refills for topical ophthalmic products consistent with the provisions of NRS 695G.172:
o (a) After 21 days or more but before 30 days after receiving any 30-day supply of the
product; (b) After 42 days or more but before 60 days after receiving any 60-day supply
of the product; or (c) After 63 days or more but before 90 days after receiving any 90-day
supply of the product.
• Medically necessary prescription drugs to treat sickle cell disease and its variants
• Human papillomavirus testing and vaccination.

90
• Drugs approved by the U.S. Food and Drug Administration for medication-assisted
treatment of opioid use disorder, including, without limitation, buprenorphine,
methadone and naltrexone.
• A drug prescribed to treat a psychiatric condition when the drug is approved by the U.S.
Food and Drug Administration or otherwise supported by medical or scientific evidence
to treat the condition and is prescribed by a health care practitioner acting within the
scope of his or her license. Step therapy is not required for such drugs.
Preventive Drug Benefit Program

48B7
The Preventive Drug Benefit Program provides participants access to certain preventive drugs subject
only to Coinsurance, without having to meet the Deductible. Coinsurance paid under the benefit will
not apply to the Deductible but will apply to Out-of-Pocket Maximum costs. The medications covered
under this benefit include categories of prescription drugs that are used for preventive purposes for
conditions such as hypertension, asthma, and high cholesterol. A list of eligible preventive drugs
covered under this benefit can be found by logging on to https://pebp.nv.gov/ or by contacting
Express Scripts.
Specialty Prescription Drugs

Specialty drugs are used to treat complex conditions, such as cancer, hemophilia, hepatitis C,
immune deficiency, multiple sclerosis, rheumatoid arthritis, etc. Specialty drugs and prescriptions
are generally limited to a 30-day supply. Specialty drugs are available only through Accredo, the
Plan’s Specialty Pharmacy. Plan participants are encouraged to register with the Specialty Pharmacy
before filling their first prescription for a specialty drug. Contact Express Scripts to determine if your
prescription is considered specialty.
Special pharmaceuticals, which include injectables, oral medications, and medications given by other
routes of delivery, may be delivered in any setting. Special pharmaceuticals are pharmaceuticals that
typically have:
• Limited access.
• Treat complex medical conditions;
• Complicated treatment regimens;
• Compliance issues;
• Special storage requirements; or
• Manufacturer reporting requirements.
Express Scripts maintains a list of special drugs classified as special pharmaceuticals. For information
regarding special pharmaceuticals, contact Express Scripts.

91
For Specialty Drugs covered under the SaveOnSP program, the coinsurance applies. For Specialty
Drugs not part of the SaveOnSP program, the applicable coinsurance applies with a copay limitation
of $100 minimum and a maximum of $250.
Preferred Retail Pharmacy Network

For short-term prescriptions, such as antibiotics, use a Preferred Retail Pharmacy (for lower copays)
or a Non-Preferred Retail Pharmacy (where you will pay $10 extra for each short-term prescription).
The Preferred Retail Pharmacy Network has more than 34,000 pharmacies consisting of
approximately 50% independent pharmacies in addition to grocers and other stores. To find a
preferred pharmacy near you, register or log in to express-scripts.com/findapharmacy or call Express
Scripts’ Member Services at 855-889-7708.
Smart90 Retail and Home Delivery Program

51B0
The Smart90 program is a feature of your prescription plan, managed by Express Scripts. With this
program, you have two ways to get up to a 90-day supply of your long-term medications (those you take
regularly for ongoing conditions). You can fill your long-term prescriptions through home delivery from
the Express Scripts Home Delivery Pharmacy or at a retail pharmacy in the Smart90 network.
Please arrange for your long-term medications to be filled with a 90-day supply through
either a participating retail pharmacy or Express Scripts Home Delivery Pharmacy. If, after a
second 30-day supply courtesy fill of your long-term medication, you do not make such
arrangements, you will pay a higher cost for your prescription medication and will not receive
credit toward your Deductible or Out-of-Pocket Maximum.
Smart90 Retail Pharmacy

To locate a participating Smart90 Retail Pharmacy or a Preferred Retail Network Pharmacy, log in to the
E-PEBP Portal located at https://pebp.nv.gov/ and select Express Scripts. You can also get pharmacy
information by calling Express Scripts’ Member Services at 855-889-7708. You can transfer your
medications easily in-store, by phone or online.
Express Scripts Home Delivery
59B8
You may use home delivery through the Express Scripts Home Delivery Pharmacy to receive a 90-day
supply of your maintenance medications and have them mailed to you with free standard shipping. Not
all drugs are available via mail order. Check with Express Scripts for further information on the availability
of your prescription medication. Enrolling in home delivery is easy! First, log in to express-scripts.com.
If you are enrolling a new prescription in home delivery:
• Contact your doctor and ask them to e-prescribe a 90-day prescription directly to Express Scripts

92
• OR send a request through Express Scripts’ website by selecting “Forms” or “Forms & Cards”
from the “Benefits” menu, print and mail-order form and follow the mailing instructions
• OR call Express Scripts’ Member Services at 855-889-77058 and they will contact your doctor for
you
Transfer retail prescriptions to home delivery by clicking “Add to Cart” for eligible prescriptions and
check out. You can also refill and renew prescriptions. Express Scripts will contact your doctor and take
care of the rest.
You may check the status and shipping of your prescriptions online or with Express Scripts’ mobile app.
Please allow 5 to 7 days from the time Express Scripts receives your prescription until it arrives at your
door. Please keep in mind, longer delivery times may be due to additional correspondence needed with
prescribers, medication availability and/or delivery times from the shipping vendor.
Generics Preferred Program

When your doctor prescribes a brand-name drug and a generic substitute is available, you will
automatically receive the generic drug unless:
• Your doctor writes “dispense as written” (DAW) on the prescription; or
• You request the brand-name drug at the time you fill your prescription.
If you choose generic medicines, you get safe medicines at lower cost. Your cost for the generic drug
will be less than the cost for the brand-name drug.
If a generic is available, but you, or your doctor, request the brand-name drug, you will pay the
applicable brand cost.
52B1
Payment assistance (manufacturer-funded patient assistance) for specialty drugs will not apply
toward your Deductible and Out-of-Pocket Maximum.
SaveOnSP Program
53B2
As part of your prescription drug plan, PEBP has partnered with an Express Scripts cost assistance
program, SaveOnSP, to help save money on certain specialty medications. When enrolled in the SaveOnSP
Program, the select specialty drugs are reimbursed by the manufacturer at no cost to the participant. The
cost of these drugs will not be applied towards satisfying your deductible or out-of-pocket maximum.
Members currently taking a medication or those who will be taking a medication that is on the SaveOnSP
Drug List, are eligible to participate in the program.

93
• Select medications on the SaveOnSP Drug List will be free of charge ($0) to members who
participate.
• Prescriptions must be filled through Accredo Specialty Pharmacy.
• The medications and associated cost included in this program are subject to the Pharmacy
Benefit Manager’s clinical rules.
• If the medication you are taking is on the SaveOnSP Drug List and you wish to participate,
call SaveOnSP at 1-800-683-1074.
Participation in the SaveOnSP Program is voluntary; however, if you are taking or will be taking
a medication that is on the SaveOnSP Drug List, and you choose not to participate in the SaveOnSP
Program, you will be responsible for the cost of the medication and the cost will not apply toward your
Deductible or Out-of-Pocket Maximum.
Diabetes Care Value

Express Scripts offers a program that supports members with diabetes (type 1 and 2), pre-diabetes, and
even common comorbidities like obesity. ESI’s digital diabetes prevention and obesity solution offers a
personalized coaching and weight loss program to help patients avoid type 2 diabetes. The Diabetes Care
Value is administered by Express Scripts and qualifying participants will receive a personal invitation, with
instructions, to join the program.
Diabetic Medications and Supplies

Participants who enroll and participate in PEBP’s Diabetes Care Management Program may receive up to
a 90-day supply of preferred diabetic supplies and the cost of those supplies will not be subject to annual
Deductible or Coinsurance requirements. Diabetic supplies under this program must be filled through
Express Scripts Home Delivery pharmacy and include blood glucose monitors, test strips, insulin, syringes,
alcohol pads, and lancets. For more information contact Express Scripts’ Member Services at 855-889-
7708.
Extended Absence Benefit
5B4
If you are going to be away from your home for an extended period, either in the country or outside of
the country, you may obtain an additional fill (30 or 90-day supply) of your prescription drugs from your
local retail or mail order pharmacy. This limited benefit must be requested from Express Scripts by the
participant in advance. A maximum of two (2) early refills are allowed every 180 days. You may be required
to obtain a new written prescription from your physician and any necessary prior authorizations.
Out-of-Country Emergency Medication Purchases
56B
o This Plan may cover emergency prescription drugs purchased if you reside in the United States and
travel to a foreign country. You will need to pay for the drug at the time of purchase and later submit
for reimbursement from Express Scripts. Prescription drug purchases made outside of the United
States are subject to Plan provisions, Benefit Limitations and Exclusions, clinical review, and

94
determination of medical necessity. The review may include application of pertinent Food and Drug
Administration (FDA) regulations. Out-of-Country medication purchases are only eligible for
reimbursement while traveling outside of the United States.
o If your purchase is eligible for reimbursement, you must use the Direct Claim Form available from
Express Scripts. Direct Claim Forms may be requested from the prescription drug plan or obtained by
logging in to www.express-scripts.com. In addition to the Direct Claim Form, you are required to
provide:
•
A legitimate, legible copy of the written prescription completed by your physician.
•
Proof of payment from you to the provider of service (typically your credit card invoice).
•
Prescription and receipt must be translated to English and include the American equivalent
National Drug Code for the prescription purchased.
• Reimbursement request must be converted to United States dollars.
Any foreign purchases of prescription medications will be subject to Plan limitations such as:
• Benefits and coverage
• Deductibles
• Coinsurance
• Dispensing maximums
• Annual benefit maximums
• Medical Necessity
• Usual and Customary (U&C) or prescription drug pharmacy benefit manager contracted
allowable
• FDA approval
• Plan prior authorization requirements
Contact Express Scripts before traveling or moving to another country to discuss any criteria that may
apply to a prescription drug reimbursement request.
Out-of-Network Pharmacy
57B6
Prescriptions filled at a domestic (inside the United States) out-of-network pharmacy location are not
authorized for reimbursement under the prescription drug Plan. Prescription drugs must be filled at a
participating in-network pharmacy location.
Other Limitations:
58B7
• This Plan does not coordinate prescription drug plan benefits with other prescription drug plans.
It is the participant’s responsibility to use the appropriate primary and secondary (if applicable)
prescription plan.

95
• See exclusions related to medications in the Benefit Limitations and Exclusions section of this
document.
The formulary is maintained by the Pharmacy Benefit Manager and may be subject to change
according to the Pharmacy Benefit Manager.

96
Benefit Limitations and Exclusions

This Plan does not cover certain services. This chapter lists the general medical and pharmacy
benefit exclusions of this Plan. Any amount you pay toward services that are not covered or
otherwise excluded will not count toward your out-of-pocket maximum. Additional exclusions
that apply to only a service or benefit are listed in the description of that service or benefit in the
Schedule of Benefits sections. This list is not all-inclusive; if you have questions about a service or
supply, contact the Claims Administrator listed in the Participant Contact Guide.
Expenses That Do Not Accumulate Toward Your Out-of-Pocket Maximum

The following services do not accumulate toward the out-of-pocket maximum, and you will be
responsible for paying these expenses out of your own pocket.
• All expenses for medical and pharmacy services and supplies that are not covered
by the Plan, to include but not limited to, expenses that exceed the CDHP network
contract rate, services listed in the Benefit Limitations and Exclusions section.
• All charges in excess of the usual and customary charge determined by the Plan
Administrator.
• Any additional amounts you must pay because you failed to comply with the
utilization management requirements described in the Utilization Management
section.
• Benefits exceeding those services or supplies subject to maximum individual or
lifetime limit(s) for certain eligible medical expenses as listed in the Schedule of
Benefits; and
• Certain wellness or preventive services that are paid by this Plan at 100% do not
accumulate towards the out-of-pocket maximum.
• The value of manufacturer rebates for drugs on the SaveOnSP non-essential drug
list.
This list is not all-inclusive and may not include certain services and supplies that are not listed
above.
Benefit Limitations
In addition to the exclusions listed below, refer to the Schedule of Benefits sections for the
maximum individual or lifetime limit(s) and any Plan Year limit applicable to certain covered
expenses. Plan Year limits are met by days, hours, visits, or dollar limits paid under all
components of the Plan.
Lifetime Maximum
This Plan imposes a lifetime maximum on some health care services and procedures. For
information on the lifetime maximums, refer to the Schedule of Benefits sections.

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Exclusions Under the Plan

The following is a list of services and supplies or expenses not covered by this Plan. The Plan
Administrator and its designees will have discretionary authority to determine the applicability
of these exclusions and terms of the Plan and determines eligibility and entitlement to Plan
benefits. Any amount you pay toward services that are not covered or otherwise excluded will
not count toward your out-of-pocket maximum.
Abortion: Elective termination of pregnancy (abortion) is excluded from the plan, other than
medically indicated abortions that are medically necessary to save the life of the mother and
complications of such abortions.
This plan provides abortion benefits in accordance with NRS 422.250.
Alternative/Complimentary Health Care Exclusions: Expenses for chelation therapy (except as

may be medically necessary for treatment of mental health, acute arsenic, gold, mercury, or lead
poisoning) and for diseases due to clearly demonstrated excess of copper or iron. Expenses for
prayer, religious healing, or spiritual healing, except services provided by a Christian Science
Practitioner. Expenses for naturopathic, Naprapathy services or treatment/supplies. Expenses for
homeopathic treatments/supplies that are not FDA approved.
Autopsy: Expenses for an autopsy and any related expenses, except as required by the Plan
Administrator or its designee.
Bariatric and Overweight Surgery: The Plan’s individual lifetime maximum is one (1) bariatric
surgery while covered under any current or previous PEBP self-funded health plan.
Bariatric and Overweight Surgery Not Performed at a Center of Excellence Provider: Benefits
are excluded for bariatric/weight loss surgery performed at an Out-of-Network facility, Out-of-
Network surgeon, or when Out-of-Network ancillary providers are used, notwithstanding
services covered under the No Surprises Act. PEBP or its designee will determine the In-Network
Center of Excellence facility.
Behavioral Health Care Exclusions
• Expenses for behavioral health care services related to:

o adoption counseling;
o non medically necessary court-ordered behavioral health care services (except
pursuant to involuntary confinement under a state’s civil commitment laws);
o custody counseling;
o dance,
o poetry, or
o art therapy;
o developmental disabilities;
o dyslexia;
o learning disorders;

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o family planning counseling;

o marriage and/or couples counseling (the exclusion for marriage/couples counseling
will not limit individual mental health counseling for an otherwise covered mental
health condition);
o intellectual disability;
o pregnancy counseling;
o vocational disabilities, and
o organic and non-organic therapies
▪ including (but not limited to) crystal healing, EST, primal therapy, L-Tryptophan,
vitamin therapy, religious/spiritual, etc.
• Expenses for tests to determine the presence of or degree of a person’s dyslexia or
learning disorder unless the visit meets the criteria for benefits payable for the diagnosis
or treatment of Autism Spectrum Disorders.
Complications of a non-covered service: Expenses for care, services or treatment required

because of complications from a treatment or service not covered under this Plan, except
complications from an abortion.
Concierge membership fees: Expenses for fees described or defined as membership, retainer or
premiums that are paid to a concierge medical practice to have access to the medical services
provided by the concierge medical practice.
Clinical Trials: See Experimental and Investigational in the Key Terms and Definitions section.
Controlled Substance or Intoxicated: Services/treatment which involve an injury to which a

contributing cause was the insured’s commission of or attempt to commit a felony, except if a
result of a medical or behavioral health condition, or domestic violence, even if the condition was
not diagnosed at the time of the injury. See NRS 695G.405.
Corrective Appliance, Orthotic Device Expenses, and Appliances: Any items that are not:
• corrective appliances,
• orthotic devices or orthotic braces that straighten or change the shape of a body part,
• prosthetic appliances, or
• durable medical equipment (as each of those terms is defined in the Key Terms and
Definitions section)
This includes, but not limited to, personal comfort items like:
• air purifiers,
• humidifiers,
• electric heating units,
• swimming pools,
• spas,
• saunas,
• escalators,
• lifts,

99
• motorized modes of transportation determined to be not medically necessary,

• pillows,
• orthopedic mattresses,
• water beds, and
• air conditioners are excluded.
Expenses for cranial helmets are excluded except for cranial helmets used to facilitate a
successful post-surgical outcome. Expenses for replacement of lost, missing, or stolen, duplicate
or personalized corrective appliances, orthotic devices, prosthetic appliances, or durable medical
equipment are not covered. Oxygen provided while traveling on an airline and portable oxygen
concentrators that are supplied for purchase or rent specifically to meet airline requirements are
excluded.
Cosmetic Services and Surgery: The Plan excludes expenses for cosmetic services, cosmetic
surgery, and any drugs used for cosmetic purposes, including but not limited to health and beauty
aids. Complications resulting from cosmetic services or cosmetic surgery are not covered. This
exclusion does not apply to breast reconstructive surgery or certain related treatments for
members who have undergone mastectomy or other treatment for breast cancer, see
Mastectomy and Reconstructive Services and Breast Reconstruction After Mastectomy section
above for details.
Prophylactic surgery is covered under certain circumstances. Contact the UM company for
information.
Participants should use the Plan’s precertification procedure to determine if a proposed surgery
or service will be considered cosmetic surgery or medically necessary reconstructive services.
Costs of Reports, Bills, etc.: Expenses for preparing medical reports, bills or claim forms;
mailing, shipping, or handling expenses; and charges for broken/missed appointments, general
telephone calls not including telehealth, or photocopying fees.
Court-Ordered Treatment: Medical and psychiatric evaluations, examinations, or treatments,

psychological testing, therapy, laboratory and other diagnostic testing and other services
including hospitalizations or partial hospitalizations and residential treatment programs that are
ordered as a condition of processing, parole, probation, or sentencing are excluded, unless the
Plan Administrator or its designee determines that such services are independently medically
necessary.
Custodial Care: Expenses for custodial care as defined in the Key Terms and Definitions section,
regardless of where they are provided, including, without limitation, adult day care, child day
care, services of a homemaker, or personal care, sitter/companion service, including any service
that can be learned to be performed or provided by a family member who is not a physician,
nurse or other skilled health care provider are not covered, even if they are medically necessary.
Services required to be performed by physicians, nurses or other skilled health care providers are
not considered to be provided for custodial care services and are covered if they are determined

100
by the Plan Administrator or its designee to be medically necessary. However, any services that
can be learned to be performed or provided by a family member who is not a physician, nurse or
other skilled health care provider are not covered, even if they are medically necessary.
Dental Services: Expenses for dental prosthetics or dental services or supplies of any kind, even
if they are necessary because of symptoms, congenital anomaly, illness, or injury affecting the
mouth or another part of the body.
Except as described as an inclusion in the Schedule of Benefits, services involving:
• treatment to the teeth;

• extraction of teeth;
• repair of injured teeth;
• general dental services;
• treatment of dental abscesses or granulomas;
• treatment of gingival tissues (other than for tumors);
• dental examinations;
• restoration of the mouth, teeth, or jaws because of injuries from
o biting,
o chewing, or
o accidents;
• artificial implanted devices;
• braces;
• periodontal care or surgery;
• teeth prosthetics and bone grafts regardless of etiology of the disease process; and
• repairs and restorations except for:
o appliances that are medically necessary to stabilize or repair sound and natural
teeth after an injury;
o dental and or medical care including mandibular or maxillary surgery,
o orthodontia treatment,
o oral surgery,
o pre-prosthetic surgery,
o any procedure involving osteotomy to the jaw, and any other dental product or
service except as set forth in the Schedule of Benefits.
Coverage for dental services as the result of an injury to sound and natural teeth may be extended
under the medical Plan to a maximum of two (2) years following the date of the injury.
Restorations past the two-year time frame will be considered under the dental benefits described
in the PEBP Self-Funded Dental PPO Plan Master Plan Document available at
https://pebp.nv.gov/.
Treatment to the gums and treatment of pain or infection known or thought to be due to dental
or medical cause and in close proximity to the teeth or jaw, braces, bridges, dental plates or other
dental orthosis or prosthesis, including the replacement of metal dental fillings; and other

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supplies and services including but not limited to cosmetic restorations, implants, cosmetic
replacements of serviceable restorations, and materials (such as precious metals).
Orthodontia is a specific Plan exclusion.
Drugs, Medicines, Nutrition or Devices:
• Pharmaceuticals requiring a prescription that have not been approved for use by the U.S.
Food and Drug Administration (FDA); have not been prescribed for a medically necessary
indication or are Experimental and/or Investigational as defined in the Key Terms and
Definitions section.
• Non-prescribed, non-Legend and over the counter (OTC) drugs or medicines (except as
preventive care medications required by the Affordable Care Act).
• Foods and nutritional supplements including (but not limited to) home meals, formulas,
foods, diets, vitamins, herbs, and minerals (regardless of whether they can be purchased
OTC or whether they require a prescription), except when provided during
hospitalization; prenatal vitamins or minerals requiring a prescription;
• Special Food Product (as defined in the Key Terms and Definitions section), except for the
benefit described as covered under Special Food Product in the Schedule of Benefits
section or elsewhere in this document under the section titled Obesity Care Management
Program;
• Naturopathic, Naprapathy, or homeopathic treatments/substances.
• Weight control or anorexiants, except those anorexiants used for treatment of children
with attention deficit hyperactivity disorder (ADHD) or individuals with narcolepsy or
where otherwise noted in this document under the section titled Obesity Care
Management Program;
• Compounded Prescriptions in which there is not at least one ingredient that is a Legend
Drug requiring a Prescription, as defined by federal or state law.
• Take-home drugs or medicines provided by a hospital, emergency room, ambulatory
surgical facility/center, or other health care facility.
• Vaccinations, immunizations, inoculations, or preventive injections that are not covered
under the Summary of Benefits section.
• Marijuana and any derivative, including CBD, THC, edibles, etc. are not a covered
benefit under this Plan.
• Non-prescription devices and drugs purchased from retail or mail-order pharmacies are
not payable under the prescription drug program.
• Drugs to enhance athletic performance such as anabolic steroids (including off-labeled
growth hormone). Coverage for human growth hormone or equivalent is excluded unless
specifically covered and described in the Summary of Benefits.
• Non-prescription male contraceptives, e.g., condoms.
• Dental products such as topical fluoride preparations and products for periodontal
disease , except as a preventive service required under the Affordable Care Act.
• Hair removal or hair growth products (i.e., Propecia, Rogaine, Minoxidil, Eflornithine, etc.).
• Vitamin A derivatives (retinoids) for dermatologic use.

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• Vitamin B-12 injections (except for treatment of mental health, pernicious anemia, other
specified megaloblastic anemias not elsewhere classified, anemias due to disorders of
glutathione metabolism, post-surgery care or other b-complex deficiencies),
antihemophilic factors including tissue plasminogen activator (TPA), acne preparations,
and laxatives (unless otherwise specified in the Schedule of Benefits.
• Anti-aging treatments (even if FDA-Approved for other clinical indications)
Durable Medical Equipment: See the exclusions related to Corrective Appliance, Orthotic Device
Expenses, and Appliances.
Educational Services: Expenses for educational/vocational services, supplies or equipment

including (but not limited to) computers, software, printers, books, tutoring, visual aids, auditory
aides, and speech aides, programs to assist with auditory perception or listening/learning skills,
programs/services to remedy or enhance concentration, memory, motivation, or self-esteem,
etc. (even if they are required because of an injury, illness, or disability of a covered individual).
Electronic cigarettes: The Plan does not cover electronic cigarettes.
Employer-Provided Services: Expenses for services rendered through a medical department,

clinic or similar facility provided or maintained by you or your covered dependents’ employer; or
for benefits otherwise provided under this Plan or any other plan that PEBP contributes to or
otherwise sponsors (e.g., HMOs).
Expenses Exceeding Maximum Plan Benefits: Expenses that exceed any Plan benefit limitation
or Plan Year maximum benefits as described in this document.
Expenses Exceeding Usual and Customary Charges, the Plan’s Maximum Allowable Charge,
Prevailing Rates and PPO Contracted Rates: Any portion of the expenses for covered medical
services or supplies that are determined by the Plan Administrator or its designee to exceed the
Plan’s Maximum Allowable Charge, Usual and Customary Charge, prevailing rates or PPO
contracted rate as defined in the Key Terms and Definitions section, except as required by
independent dispute resolution under the No Surprises Act.
Expenses for Which a Third-Party Is Responsible: See “Third-Party Liability” of the Health and
Welfare Wrap document that can be found on https://pebp.nv.gov/ (NAC 287.755).
Expenses Incurred Before or After Coverage: Expenses for services rendered or supplies
provided either before the patient became covered under the Plan or after the date the patient’s
coverage ends, except under those conditions described in COBRA Continuation Coverage.
Experimental and/or Investigational Services: Unless mandated by law, expenses for any
medical services, supplies, drugs, or medicines that are determined by the Plan Administrator,
UM company or its designee to be experimental and/or investigational services.

103
Fertility and Infertility Treatment:

Except as otherwise specified in the Schedule of Benefits section, all other costs incurred for
reproduction by artificial means or assisted reproductive technology (such as in-vitro fertilization,
or embryo transplants) are excluded. This exclusion includes treatments, testing, services,
supplies, devices, or drugs intended to produce a pregnancy; the promotion of fertility including,
but not limited to, fertility testing (except as otherwise covered and described above); serial
ultrasounds; services to reverse voluntary surgically-induced infertility; reversal of surgical
sterilization; any service, supply, or drug used in conjunction with or for the purpose of an
artificially induced pregnancy, test-tube fertilization; the cost of donor sperm or eggs; in-vitro
fertilization and embryo transfer or any artificial reproduction technology or the freezing of
sperm or eggs or storage costs for frozen sperm, eggs, or embryos; including, but not limited to,
determining, evaluating, or enhancing the physical or psychological readiness for pregnancy,
procedures to improve the participant’s ability to become pregnant or to carry a pregnancy to
term; and any payment made by or on behalf of a participant who is contemplating or has
entered into a contract for surrogacy to a provider or individual related to any services potentially
included in the scope of surrogacy services; sperm donor for profit or prescription (infertility)
drugs; or GIFT or ZIFT procedures, low tubal transfers, or donor egg retrieval are also excluded.
Foot/Hand Care:
Expenses for non-symptomatic foot care such as the removal of warts (except plantar warts);
corns or calluses; and including but not limited to podiatry treatment of bunions, toenails, flat
feet, fallen arches, and chronic foot strain; and expenses for routine foot care (including but not
limited to: trimming of toenails, removal of corns and callouses, preventive care with assessment
of pulses, skin condition and sensation) or hand care, (including manicure and skin conditioning),
unless the Plan Administrator or its designee determines such care to be medically necessary.
Routine foot care from a podiatrist for treatment of foot problems such as corns, calluses and
toenails are payable for individuals with a metabolic disorder such as diabetes, or a neurological
or peripheral-vascular insufficiency affecting the feet.
Genetic Testing and Counseling: Coverage is not available for tests solely for research, or for the
benefit of individuals not covered under this Plan.
Expenses for genetic testing and counseling are excluded, unless otherwise specified in this Plan’s
Schedule of Benefits.
Growth Hormone: Coverage for off-labeled growth hormone.
Gym Fees: Fees by personal trainers or gym or health club memberships, exercise programs, or
exercise physiologists, even if recommended by a professional to treat a medical condition.
Hair: Expenses for or related to hair removal, hair transplants and other procedures to replace
lost hair or to promote the growth of hair, including prescription and non-prescription drugs such
as Minoxidil, Propecia, Rogaine, Eflornithine; or for hair replacement devices, including (but not
limited to) wigs, toupees and/or hairpieces or hair analysis. Patients undergoing chemotherapy

104
may be able to receive benefits for some hair replacement devices, as set forth in the
“Chemotherapy” section in the Schedule of Benefits.
Hearing Care: Special education and associated costs in conjunction with sign language education
for a patient or family members.
Hearing Aids: Over the Counter hearing aids are excluded from the Plan.
Home Birth/Delivery: Planned birth/delivery at home and associated services are not covered by
this Plan. Guidelines for Perinatal Care published by the American Academy of Pediatrics and
American College of Obstetricians and Gynecologists (ACOG) that the hospital, including a
birthing center within the hospital complex, or a freestanding birthing center, provides the safest
setting for labor, delivery, and the postpartum period. The use of other settings is not covered
by this Plan. Facilities providing obstetrical care should have the services listed as essential
components of a Level 1 hospital.
Home Health Care:
• Expenses for any home health care services that are not medically necessary, other than
part-time, intermittent skilled nursing services and supplies.
• Expenses for a homemaker, custodial care, childcare, adult care, or personal care
attendant, except as provided under the Plan’s hospice coverage.
• Expenses for any home health care services that is not provided by an organization or
professional licensed by the state to render home health services.
• Over-the-counter medical equipment supplies or any prescription drugs, except
otherwise provided in the Summary of Benefits and Schedule of Benefits.
Expenses for any services provided substantially or primarily for the participant’s convenience
or the convenience of a caregiver.
Hospital Employee, Medical Students, Interns or Residents: Expenses for the services of an
employee of a hospital, skilled nursing facility or other health care facility, when the facility is
obligated to pay that employee.
Hypnosis and Hypnotherapy: An artificially induced alteration of consciousness in which the

patient is in a state of increased suggestibility.
Illegal Act: Expenses incurred by a covered individual for injuries resulting from commission (or
attempted commission by the covered individual) of an illegal act as determined by the plan
administrator which involved violence or threat of violence to another person, or in which any
weapon or explosive is used by the covered individual, unless such injury is the result of a physical
or mental health condition or domestic violence. The Plan Administrator’s determination that
this exclusion applies shall not be affected by any prosecution, or acquittal of (or failure to
prosecute) the covered individual in connection with the acts involved, unless such injury is the
result of a physical or mental health condition or domestic violence.

105
Internet/Virtual Office Visit: Expenses related to an online internet consultation with an out-of-
network physician or other health care practitioner (also called a virtual office visit/consultation),
physician-patient web service or physician-patient e-mail service (including receipt of advice,
treatment plan, prescription drugs or medical supplies obtained) from an online internet provider
who is not a participating provider in the Plan network except as specifically provided.
Maternity/Family Planning:
• Contraception: Expenses related to prescription or non-prescription male contraceptive

drugs and devices such as condoms.
• Termination of Pregnancy: Expenses for elective termination of pregnancy (abortion) unless
the attending physician certifies the health of the mother would be endangered if the fetus
were carried to term and complications of such termination.
• Childbirth courses.
• Expenses related to delivery associated with a pregnant dependent child, except for
expenses related to complications of pregnancy.
• Expenses related to cryo-storage of umbilical cord blood or other tissue or organs.
• For nondurable supplies.
• Reversal of prior sterilization procedures, including, but not limited to tubal ligation and
vasectomy reversals.
Medically Unnecessary Services: Services or supplies determined by the Plan Administrator or

its designee not to be medically necessary, as defined in the Key Terms and Definitions section.
Modifications of Homes or Vehicles: Expenses for construction or modification to a home,

residence or vehicle required because of an injury, illness, or disability of a covered individual,
including, without limitation, any construction or modification (e.g., ramps, elevators, chair lifts,
swimming pools, spas, air conditioning, asbestos removal, air filtration, handrails, emergency
alert system, etc.).
No-Cost Services: Expenses for services rendered or supplies provided without cost, or for which
there would be no charge if the person receiving the treatment were not covered under this Plan.
No Provider Recommendation or Order: Expenses for services rendered or supplies provided

that are not recommended or prescribed by a physician or other licensed provider acting within
the scope of their license.,
Non-Emergency Hospital Admission: Care and treatment billed by a hospital for a non-medical
emergency admission on a Friday or Saturday unless surgery is performed within 24 hours of the
admission.
Non-Emergency Travel and Related Expenses: Expenses for and related to non-emergency travel
or transportation (including lodging, meals, and related expenses) of a health care provider,
participant except where otherwise specified in the Utilization Management section for organ/
tissue transplants and bariatric weight loss surgery or certain surgeries performed in a surgery

106
center, inpatient hospital or outpatient setting as determined by the Plan Administrator or the
UM company.
Occupational Illness, Injury or Conditions Subject to Workers’ Compensation: All expenses

incurred by you or any of your covered dependents arising out of or during employment if the
injury, illness, or condition is subject to coverage, in whole or in part, under any workers’
compensation, or occupational disease (or similar) law.
Orthodontia: Expenses for any services relating to orthodontia evaluation and treatment even if
the orthodontia services are provided as the result of an injury or illness.
Personal Comfort Items: Expenses for patient convenience, including (but not limited to) care of
family members while the covered individual is confined to a hospital (or other health care
facility, or to bed at home), guest meals, television, VCR/DVD, telephone, barber or beautician
services, house cleaning or maintenance, shopping, birth announcements, photographs of new
babies, etc.
Private Room in a Hospital or Health Care Facility: The use of a private room in a hospital or
other health care facility, unless the facility has only private room accommodations, or unless the
use of a private room is certified as medically necessary by the Plan Administrator or its designee.
Prophylactic Surgery or Treatment: Unless otherwise noted in this document, expenses for
medical or surgical services or procedures, including prescription drugs and the use of
prophylactic surgery, as defined in the Key Terms and Definitions section of this document, when
the services, procedures, prescription of drugs, or prophylactic surgery is prescribed or
performed for:
• Avoiding the possibility or risk of an illness, disease, physical or mental disorder or condition
based on family history and/or genetic test results, in certain circumstances; or
• Treating the consequences of chromosomal abnormalities or genetically transmitted
characteristics when there is an absence of objective medical evidence of the presence of
disease or physical or mental disorder. Participants should use the Plan’s UM company to
assist in the determination of a proposed surgery to determine if it is or is not covered under
this Plan.
NOTE: Some prophylactic surgeries may be covered under this Plan if certain criteria are met.
Please refer to the Schedule of Benefits section. For additional information, please contact this
Plan’s UM company or Claims Administrator.
Prophylactic drugs are excluded.
Rehabilitation Therapy (Inpatient or Outpatient):

• Expenses for educational, job training, vocational rehabilitation, and/or special education
for sign language.
• Expenses for massage therapy, Rolfing, and related services.

107
• Expenses incurred at an inpatient rehabilitation facility for any inpatient rehabilitation

therapy services provided to an individual who is unconscious, comatose, or in the
judgment of the Plan Administrator or its designee, is otherwise incapable of conscious
participation in the therapy services and/or unable to learn and/or remember what is
taught, including (but not limited to) coma stimulation programs and services.
• Expenses for maintenance rehabilitation, as defined in the Key Terms and Definitions
section.
• Expenses for speech therapy for functional purposes including (but not limited to)
stuttering, and stammering.
• Expenses for cognitive therapy are excluded unless related to short-term services
necessitated by a catastrophic neurological event to restore functioning for activities of
daily living or for Medically Necessary treatment of a mental health or substance use
disorder diagnosis.
• Therapies, psychological services, counseling, or tutoring services for developmental
delay or learning disability.
• Treatment that a federal or state law mandates that coverage be provided and paid for
by a school district or other governmental agency.
Service Animals: Purchase, training, or maintenance of any type of service animal, even if
designated as medically necessary.
Smoking/Tobacco Cessation: Expenses for non-prescription (over the counter) tobacco/smoking

cessation products such as nicotine gum or patches, unless prescribed by a physician. There are
no benefits payable for the use of electronic cigarettes. Prescription smoking/tobacco cessation
products are payable under the prescription drug benefit as described in the Schedule of Benefits
section.
Stand-By Physicians or Health Care Practitioners: Expenses for any physician or other provider
who did not directly provide or supervise medical services to the patient, even if the physician or
practitioner was available on a stand-by basis.
Taxes: Sales taxes, unless specifically covered in the Plan.
Telephone Calls: Expenses for all telephone calls between a physician or other health care
provider and any patient, other health care provider, UM company or vendor; or any
representative of this Plan for any purpose whatsoever.
Transplant (Organ and Tissue) Experimental and/or Investigational:

Human organ and/or tissue transplants that are experimental and/or Investigational, including
(but not limited to) donor screening, acquisition and selection, organ or tissue removal,
transportation, transplants, post-operative services and drugs or medicines, and all
complications thereof.
Non-human (Engrafted) organ and/or tissue transplants or implants, except heart valves.

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• Expenses incurred by the person who donates the organ or tissue, unless the person who
receives the donated organ/tissue is the person covered by this Plan
Travel Outside of the United States: Any services received outside the United States are excluded
unless deemed to be urgent or emergency care.
Vision Care:
Charges for the fitting and cost of visual aids, vision therapy, eye therapy, orthoptics with eye
exercise therapies, refractive errors including but not limited to eye exams and surgery done in
treating myopia (except for corneal graft); ophthalmological services provided in connection with
the testing of visual acuity for the fitting for eyeglasses or contact lenses, eyeglasses or contact
lenses (except coverage for the first pair of eyeglasses or contact lenses following cataract
surgery); and surgical correction of near or far vision inefficiencies such as laser and radial
keratotomy are excluded, except as otherwise specified in this Plan’s Summary of Benefits and
Schedule of Benefits.
War or Similar Event: Expenses incurred because of an injury or illness due to you or your covered
dependent(s)’ participation in any act of war, either declared or undeclared, war-like act, riot,
insurrection, rebellion, or invasion, except as required by law.
Weight Management and Physical Fitness:

• Medical or surgical treatment for weight-related disorders including (but not limited to)
surgical interventions, dietary programs, and prescription drugs, except those services
specified in the Summary of Benefits and Schedule of Benefits. Surgery for weight reduction
must be performed at a Bariatric Center of Excellence. Expenses for weight loss surgery
performed without a precertification from the UM company will be denied.
• Expenses related to programs such as Weight Watchers, Jenny Craig, Nutri-Systems, Slim
Fast or the rental or purchase of any form of exercise equipment.
• Expenses for medical or surgical treatment of severe underweight, including (but not limited
to) high calorie and/or high protein food supplements or other food or nutritional
supplements, except in conjunction with medically necessary treatment of an eating
disorder (such as anorexia, bulimia, etc.). Severe underweight means a weight more than
25 percent under normal body weight for the patient’s age, sex, height, and body frame
based on weight tables generally used by physicians to determine normal body weight.
• Expenses for memberships in or visits to health clubs, exercise programs, gymnasiums,
and/or any other facility for physical fitness programs, including exercise equipment.
• One obesity related surgery per lifetime while covered under any PEBP self-funded medical
Plan (e.g., LD PPO Plan, CDHP, and Exclusive Provider Organization Plan).
Other Benefit Exclusions

• Stress reduction therapy or cognitive behavior therapy for sleep disorders.
o The exclusion for cognitive therapy does not apply to Medically Necessary treatment of a
mental health or substance use condition.

109
• Sleep therapy (except for central or obstructive apnea when medically necessary and when a
precertification has been received from the UM company), behavioral training or therapy,
milieu therapy (unless the care is otherwise medically necessary), biofeedback (unless
included with psychotherapy), behavior modification, sensitivity training, hypnosis, electro
hypnosis, electro-sleep therapy, electro-narcosis, massage therapy, and gene therapy.
• Charges that result from appetite control or any treatment of obesity, unless otherwise
provided in the Summary of Benefits and Schedule of Benefits.
• Aroma therapy, massage therapy, reiki therapy, thermograph, orthomolecular therapy,
contact reflex analysis, Bio-Energetic Synchronization Technique (BEST), colonic irrigation,
magnetic innervation therapy and electromagnetic therapy.
• Natural and herbal remedies that may be purchased without a prescription (over the
counter), through a web site, at a Physician or Chiropractor’s office, or at a retail location are
excluded, unless otherwise specified in the Summary of Benefits and Schedule of Benefits.

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Medical Claims Administration
Claims Administration
How Benefits are Paid
Plan benefits are considered for payment on the receipt of written proof of claim, commonly
called a bill. Generally, health care providers send their bill to PEBP’s third-party claims
administrator directly. Plan benefits for eligible services performed by health care providers will
then be paid directly to the provider delivering the services. When deductibles, coinsurance or
copayments apply, you are responsible for paying your share of these charges.
If a health care provider does not submit a claim directly to PEBP’s third-party claims
administrator and instead sends the bill to you, you should follow the steps outlined in this
section regarding How to File a Claim. If, at the time you submit your claim, you furnish evidence
acceptable to the Plan administrator or its designee (PEBP’s third-party claims administrator) that
you or your covered dependent paid some or all those charges, Plan benefits may be paid to you,
but only up to the amount allowed by the Plan for those services after Plan Year Deductible and
Coinsurance amounts are met.
How to File a Claim

All claims must be submitted to the Plan within 12 months from the date of service. No Plan
benefits will be paid for any claim submitted after this period. Benefits are based on the Plan’s
provisions in place on the date of service.
Most providers send their bills directly to the PEBP’s claims administrator; however, for providers
who do not bill the Plan directly, you may be sent a bill. In that case, follow these steps:
• Obtain a claim form from PEBP’s third-party claims administrator or PEBP’s

website (see the Participant Contact Guide in this document for details on address,
phone, and website).
• Complete the participant part of the claim form in full. Answer every question,
even if the answer is “none” or “not applicable (N/A).”
• The instructions on the claim form will tell you what documents or medical
information is necessary to support the claim. Your physician, health care
practitioner or dentist can complete the health care provider part of the claim
form, or you can attach the itemized bill for professional services if it contains all
the following information:
• A description of the services or supplies provided including appropriate procedure
codes.
• Details of the charges for those services or supplies.
• Appropriate diagnosis code.
• Date(s) the services or supplies were provided.
• Patient’s name.
• Provider’s name, address, phone number, and professional degree or license.
• Provider’s federal tax identification number (TIN).

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Medical Claims Administration
• Provider’s signature.
Please review your bills to be sure they are appropriate and correct. Report any discrepancies in
billing to the Claims Administrator. This can reduce costs to you and the Plan. Complete a
separate claim form for each person for whom Plan benefits are being requested. If another plan
is the primary payer, send a copy of the other plan’s Explanation of Benefits (EOB) along with the
claim you submit to this Plan.
To assure that medical, pharmacy or dental expenses you incur are eligible under this Plan, the
Plan has the right to request additional information from any hospital, facility, physician,
laboratory, radiologist, dentist, pharmacy or any other eligible medical or dental provider. For
example, the Plan has the right to deny Deductible and Out-of-Pocket Maximum credit or
payment to a provider if the provider’s bill does not include necessary information such as:
• Itemization of services;
• Proper billing codes such as CPT, HCPCS, Revenue Codes, CDT, ICD 9, and ICD 10;
• Date(s) of service;
• Place of service;
• Provider’s Tax Identification Number;
• Provider’s signature;
• Operative report;
• Patient ledger; or
• Emergency room notes, if applicable.
Providers such as hospitals and facilities that bill for single or bulk items such as
orthopedic devices/implants or other types of biomaterials shall provide to the third-
party claim’s administrator a copy of the manufacturer’s/organization’s invoice (that
directly supplied the device/implant/biomaterial to the healthcare provider). This Plan
will deny payment for such medical devices until a copy of the invoice is provided to this
Plan’s Claims Administrator.
Claims are processed by the third-party claims administrator in the order that they are received.
It is your responsibility to maintain copies of the EOB documents provided to you by PEBP’s third-
party claims administrator or prescription drug administrator. Copies of EOB documents are
available on the Claims Administrator’s website but cannot be reproduced. PEBP and its third-
party claims administrator do not provide printed copies of EOB documents outside of the
original mailing.
Where to Send the Claim Form

Send the completed claim form, the bill you received (retain a copy for your records) and any
other required information to the Claims Administrator at the address listed in the Participant
Contact Guide in this document.

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Appeals
You have the right to ask PEBP or its designees to reconsider a claim or Utilization Management
Adverse Benefit Determination resulting in a denial, reduction, termination, failure to provide or
make payments (in whole or in part) for a service or treatment, rescission of coverage (retroactive
cancellation), or HRA claim.
Discretionary Authority of PEBP and Designee

In carrying out their respective responsibilities under the Plan, PEBP and its designees have
discretionary authority to interpret the terms of the Plan and to determine eligibility and
entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or
determination made under that discretionary authority would be given full force and effect
unless it can be shown that the interpretation or determination was arbitrary and capricious.
Services that are covered, as well as specific Plan exclusions are described in this document.
Claims and HRA Appeals

Written Notice of Adverse Benefit Determination
The Plan or its designee, the third-party administrator, will notify you in writing on an Explanation
of Benefits (EOB) of an Adverse Claim Determination resulting in a denial, reduction, termination,
or failure to provide or make payments (in whole or in part) of a benefit. The notice will explain
the reasons why, with reference to the Plan provisions as to the basis for the adverse
determination and it will explain what steps to take to submit a Level 1 Claim Appeal. When
applicable, the notice will explain what additional information is required from you and why it is
needed. A participant or their designee cannot circumvent the claims and appeals procedures by
initiating a cause of action against the PEBP (or the State of Nevada) in a court proceeding.
You will be provided with:
(a) upon request and without charge, reasonable access to and copies of all relevant
documents, records and other information relevant to your claim for benefits;
(b) the opportunity to submit written comments, documents, records and other information
relating to the claim for benefits;
(c) a full and fair review that considers all comments, documents, records and other
information submitted by you, without regard to whether such information was
submitted or considered in the initial benefit determination;
(d) automatically and free of charge, with any new or additional evidence considered, relied
upon, or generated by the Plan (or at the direction of the Plan) in connection with the
denied claim. Such evidence will be provided as soon as possible (and sufficiently in
advance of the date on which the notice of Adverse Benefit Determination on review is
required to be provided) to give you a reasonable opportunity to respond prior to that
date.

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Additionally, before the Plan issues an Adverse Benefit Determination on review based on a new
or additional rationale, you will be provided, automatically and free of charge, with the rationale.
The rationale will be provided as soon as possible (and sufficiently in advance of the date on
which the notice of Adverse Benefit Determination on review is required to be provided) to give
you reasonable time to respond prior to that date.
If the Plan receives new or additional evidence or rationale so late in the claim filing or claim
appeal process that a claimant would not have a reasonable opportunity to respond, the period
for providing a final determination is delayed until such time as the claimant has had such an
opportunity.
Level 1 Claim Appeal

NAC 287.670
If your claim is denied, or if you disagree with the amount paid on a claim, you may request a
Level 1 Claim Appeal from the third-party administrator within 180 days of the date you received
the Explanation of Benefits (EOB) which provides the claim determination. Failure to request a
Level 1 Claim Appeal in a timely manner will be deemed to be a waiver of any further right of
review of appeal under the Plan, unless good cause can be demonstrated. The written request
for appeal must include:
• The name and Social Security Number, or identification number of the participant.
• A copy of the EOB related to the claim being appealed; and
• A detailed written explanation why the claim is being appealed.
You have the right to review documents applicable to the denial and to submit your own
comments in writing. The third-party administrator will review your claim (by a person at a higher
level of management than the one who originally denied the claim). If any additional information
is needed to process your request for appeal, it will be requested promptly.
The third-party administrator will issue a decision of your Level 1 Claim Appeal in writing within
20 days after receipt of your request for appeal.
You will receive a notice of the appeal determination. If that determination is adverse, it will
include at each level of the appeal review, the following:
(a) information that is sufficient to identify the claim involved (e.g., date of service, health
care provider, claim amount if applicable);
(b) the statement that, upon request and free of charge, the diagnosis code and/or treatment
code, and their corresponding meanings, will be provided. However, a request for this
information will not be treated as a request for a 2 nd level of appeal or external review
(when external review is applicable);
(c) the specific reason(s) for the adverse appeal review decision, including the denial code
and its corresponding meaning and a discussion of the decision, as well as any Plan
standards used in denying the claim;
(d) reference the specific Plan provision(s) on which the determination is based;

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(e) a statement that you are entitled to receive upon request, free access to and copies of
documents relevant to your claim;
(f) an explanation of the Plan’s appeal process and Level 2 appeal process and the external
review process (when external review is applicable), along with any time limits and
information regarding how to initiate the next level of review, as well as a statement of
the voluntary Plan appeal procedures, if any;
(g) if the denial was based on an internal rule, guideline, protocol or similar criterion, a
statement will be provided that such rule, guideline, protocol or criteria that was relied
upon will be provided free of charge to you, upon request;
(h) if the denial was based on medical necessity, experimental treatment, or similar exclusion
or limit, a statement will be provided that an explanation regarding the scientific or
clinical judgment for the denial will be provided free of charge to you, upon request;
(i) the statement that “You and your Plan may have other voluntary dispute resolution
options such as mediation. One way to find out what may be available is to contact your
local U. S. Department of Labor Office and your State insurance regulatory agency;” and
(j) disclosure of the availability of, and contact information for, any applicable health
insurance consumer assistance or ombudsman established under the Public Health
Services Act to assist individuals with internal claims and appeals and external review
processes (when external review is applicable).
The notification will explain the steps necessary if you wish to proceed to a Level 2 Appeal if you
are not satisfied with the response at Level 1.
Level 2 Claim Appeal

NAC 287.680
If you are unsatisfied with the Level 1 Claim Appeal decision made by the third-party
administrator, you may file a Level 2 Claim Appeal to the PEBP Executive Officer or designee by
completing a Claim Appeal Request form. Claim Appeal Request forms are available at
https://pebp.nv.gov/ or by request by contacting PEBP Customer Service. Furthermore, you are
welcome to submit Level 2 Claim Appeals online through a form that can be found under the
subheading “Filing an Appeal” under PEBP’s contact us web page. A Level 2 Appeal must be
submitted to PEBP within 35 days after you receive the Level 1 Appeal determination. Your Level
2 Appeal must include a copy of:
• Any document submitted with your Level 1 Appeal request.
• A copy of the Level 1 Appeal decision; and
• Any documentation to support your request.
The Executive Officer or designee will use all resources available to ensure a thorough review is
completed in accordance with provisions of the Plan.
A Level 2 Appeal decision will be given to you in writing by certified mail within 30 days after
the Level 2 Appeal request is received by the Executive Officer or designee. A Level 2 Appeal

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determination will explain and reference the reasons for the decision, including the applicable
provisions of the Plan upon which the determination is based.
External Claim Review

NAC 287.690
Standard Request
An External Claim Review may be requested by a participant and/or the participant’s treating
physician after exhausting the Level 1 and Level 2 Claim Appeals process. This means that you
may have a right to have the Plan’s or its designee’s decision reviewed by independent health
care professionals if the adverse benefit determination involved making a judgment as to the
medical necessity, appropriateness, health care setting, level of care or effectiveness of the
health care setting or treatment you requested.
An External Claim Review request must be submitted in writing to the Office for Consumer Health
Assistance (OCHA) within four (4) months after the date of receipt of a notice of the Level 2 Claim
Appeal decision. An External Review Request Form is available on the PEBP website at
https://pebp.nv.gov/. The OCHA will assign an independent external review organization within
five 5 days after receiving the request. The external review organization will issue a
determination within 15 days after it receives the complete information. For standard Request
for External Claim Review, a decision will be made within 45 days of receiving the request.
A Request for External Claim Review must include:

• completed and signed External Review Request Form.
• a copy of the EOB(s) related to the claim(s) being reviewed.
• a detailed written explanation why the external review is being requested; and
• any additional supporting documentation.
The Request for External Claim Review must be submitted to:

Office for Consumer Health Assistance
7150 Pollock Dr
Las Vegas, NV 89119
Phone: (702) 486-3587,
(888) 333-1597
Web:
https://adsd.nv.gov/Programs/CHA/Office_for_Consumer_Health_Assistance_(OCHA)/
Appealing a Utilization Management Determination

The utilization management (UM) company is staffed with licensed health care professionals,
who utilize nationally recognized health care screening criteria along with the medical judgment
of their licensed health care professional, operating under a contract with the Plan to administer
utilization review services. The review includes a process to determine the medical necessity,
appropriateness, location, and cost effectiveness of health care services. Depending on the
service, a review may occur before, during, or after the services are rendered, including, but not

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limited to precertification/pre-authorization; concurrent and/or continued stay review;

discharge planning; retrospective review; and case management.
Pursuant to applicable provisions of NRS Chapter 695G, you have the following appeal processes
for any adverse benefit determination made during the precertification, concurrent review,
retrospective review, or case management. An appeal may be initiated by the participant,
treating provider, parent, legal guardian, or person authorized to make health care decisions by
a power of attorney.
The UM company will utilize a physician (other than the physician who rendered the original
decision) to review the appeal. This physician is Board Certified in the area under review and is
in active practice. Refer to the Participant Contact Guide for the UM company’s contact
information.
Internal UM Appeal Review

Expedited Internal UM Appeal Review
You may request an expedited appeal review of a denied precertification of a hospital admission,
availability of care, continued stay or health care service for which you received emergency
services but have not been discharged from the facility providing the care; or if the physician
certifies that failure to proceed in an expedited manner may jeopardize your life or health or the
life or health of your covered dependent or the ability for you or your covered dependent to
regain maximum function.
Requests for an expedited internal UM appeal review may be made by telephone or any other
reasonable means to the UM company that will ensure the timely receipt of the information
required to complete the appeal process. If your physician requests a consultation with the
reviewing physician, this will occur within one business day. The UM company will decide on an
expedited appeal within 72 hours of receipt of the information needed to complete the appeal.
The results of the determination of an expedited appeal will be provided immediately to the
managing physician by phone and in writing to the patient, managing physician, facility, and the
third-party claim’s administrator.
If the appeal review request is denied, the UM company will provide the member with an adverse
benefit determination letter including the clinical rationale for the non-certification decision and
the member may pursue an external appeal as described in NRS 695G.241 - NRS 695G.275.
Standard Internal UM Appeal Review

If you have a denied precertification request (or a denial/non-certification at any other level of
UM review such as concurrent review, retrospective review, or case management issue) and you
do not qualify for an expedited appeal, you may request a standard appeal review. Requests for
standard appeal review may be made by writing to the UM company.
Requests for standard appeal review must be made within 180 days of the date of the denial/non-
certification. Actual medical records are encouraged to be provided to assist the reviewer.

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Standard appeals for pre-service denials will be reviewed by a physician within 15 days of the UM
company’s receipt of the request. Appeals for post-service treatment will be completed within
20 days of the receipt of the request. The results of the determination of a standard appeal will
be provided in writing to the patient, managing physician, facility, and third-party claim’s
administrator.
A participant or their designee can choose to bypass the internal appeals process from adverse
benefit determinations resulting from the UM company and request a review by an external
review organization.
External UM Appeal Review

An external review may be requested by a participant and/or the participant’s treating physician
after you have exhausted the internal UM appeal review process. This means you may have the
right to have the Plan Administrator or its designee’s decision reviewed by independent health
care professionals if the adverse benefit determination involved making a judgement as to the
medical necessity, appropriateness, health care setting, level of care or effectiveness of the
health care setting or treatment you requested.
Expedited Request for External Review (Pre-Service Urgent UM Appeal)

NRS 287.04335
For adverse benefit determinations resulting from the UM company, a participant or their
designee can choose to bypass the internal UM appeal process and request a review by an
external review organization.
Expedited external review is available only if the request is filed within four (4) months after the
date of receipt of a notice of an adverse benefit determination and the patient’s treating provider
certifies that adherence to the time frame for the standard external review would seriously
jeopardize the life or health of the covered individual or would jeopardize the covered
individual’s ability to regain maximum function. Pursuant to NRS 695G.271, the Office for
Consumer Health Assistance (OCHA) will approve or deny a request for an external review of an
adverse determination not later than 72 hours after receipt from the provider. If OCHA
determines the request qualifies for expedited review, a final of the external review will made by
the external review organization within 72 hours of receipt and the provider and participant will
be notified within 24 hours.
A participant may file a request for an expedited external review with the Office for Consumer
Health Assistance (OCHA) if the request is filed within four (4) months after the date of receipt of
a notice of an adverse benefit determination or final internal adverse benefit determination. An
expedited external review request form, which includes a certification of treating provider for
expedited consideration can be found on the PEBP website at https://pebp.nv.gov/.
The request must be submitted to:


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7150 Pollock Dr
Las Vegas, NV 89119
Phone: (702) 486-3587,
(888) 333-1597
Web:
https://adsd.nv.gov/Programs/CHA/Office_for_Consumer_Health_Assistance_(O
CHA)/
Standard Request for External UM Review

A standard request for external UM review may be filed with the Office for Consumer Health
Assistance (OCHA) if the request is filed within four (4) months after the date of receipt of a notice
of an adverse benefit determination or final internal adverse benefit determination. A standard
external review request form can be found on the PEBP website at https://pebp.nv.gov/.
A standard external review decision will be made within 45 days of OCHA’s receipt of the request.
As with the expedited external review, a standard external review must be submitted to the
Office for Consumer Health Assistance at the contact information listed above.
Experimental and/or Investigational Claim/UM External Review

If you received a denial for a service, durable medical equipment, procedure, or other therapy
because the third-party administrator or the UM company determined it to be experimental
and/or investigational, or subject to the No Surprises Act, or rescission of coverage, you may
request an external review. To proceed with the experimental and/or investigational external
review, you must obtain a certification from the treating physician indicating that the treatment
would be significantly less effective if not received.
A “Physician Certification of Experimental/Investigational /Denials” is located under “Forms” on

the PEBP website at https://pebp.nv.gov/.
After this form is completed by the treating physician, it should be attached to the Request for
External Review” form and submitted to the Office for Consumer Health Assistance at:

7150 Pollock Dr
Las Vegas, NV 89119
Phone: (702) 486-3587,
(888) 333-1597
Web: https://adsd.nv.gov/Programs/CHA/Office_for_Consumer_Health_Assistance_(OCHA)/
Prescription Drug Review and Appeals

A participant has the right to request that a medication be covered or be covered at a higher
benefit (e.g., lower copay, higher quantity, etc.). The first request for coverage is called an initial

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coverage review. The Pharmacy Benefit Manager reviews both clinical and administrative
coverage review requests, including those cases related to specialty drugs dispensed through
Accredo specialty pharmacy.
Clinical Coverage Review

The initial clinical coverage review is a request for coverage or medication that is based on clinical
conditions of coverage that are set by this Plan—for example, medications that require a prior
authorization. To make an initial determination for a clinical coverage review request, the
prescribing physician must submit specific information for review.
How to Request a Clinical Coverage Review

The preferred method to request an initial clinical review is for the prescribing physician to
submit the prior authorization request electronically. Alternately, the participant’s prescribing
physician or pharmacist may call Express Scripts at 1-800-753-2851 or the prescriber may submit
a request in writing using a Benefit Coverage Review Form, which can be obtained by calling
Express Scripts Member Services at 1-855-889-7708. (Home delivery coverage review requests
are automatically initiated by the home delivery pharmacy as part of filling the prescription.)
Administrative Coverage Review

The initial administrative coverage review is a request for coverage of a medication that is based
on the Plan’s benefit design.
How to Request an Administrative Coverage Review

To request an initial administrative coverage review, the participant must submit the request in
writing to Express Scripts to the attention of the Benefit Coverage Review Department (see
Participant Contact Guide section).
For an administrative coverage review request, the participant must submit information to the
pharmacy benefits manager to support the request.
If the patient’s situation meets the definition of urgent under the law, an urgent review may be
requested and conducted as soon as possible, but no later than 72 hours from receipt of request.
In general, an urgent situation is one which, in the opinion of the attending provider, the patient’s
health may be in serious jeopardy, or the patient may experience pain that cannot be adequately
controlled while the patient waits for a decision on the review. If the patient or provider believes
the patient’s situation is urgent, the expedited review must be requested by calling Express
Scripts at 1-800-753-2851.
If the necessary information is provided to Express Scripts so that a determination can be made,
the initial determination and notification for a clinical coverage or administrative coverage review
will be made within the timeframe below:
• Standard Pre-Service: 15 days for retail pharmacy and five (5) days for home
delivery; and
• Standard Post-Service: 30 days.

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Level 1 Appeal or Urgent Appeal

When an initial administrative or clinical coverage review request has been denied, a request for
appeal of the denial may be submitted by the participant within 180 days from receipt of notice
of the initial adverse benefit determination. To initiate an appeal, the following information must
be submitted by mail or fax to Express Scripts’ Benefit Coverage Review Department:
• Name of patient.
• Participant ID number.
• Phone number.
• The drug name for which benefit coverage has been denied.
• Brief description of why the claimant disagrees with the initial adverse benefit
determination; and
• Any additional information that may be relevant to the appeal, including
physician/prescriber statements/letters, bills, or any other documents.
An urgent appeal may be submitted if in the opinion of the attending provider, the application of
the time periods for making non-urgent care determinations could seriously jeopardize the life
or health of the patient or the patient’s ability to regain maximum function or would subject the
patient to sever pain that cannot be adequately managed without the care or treatment that is
the subject of the claim.
Urgent appeals must be submitted by phone at 1-800-753-2851 or fax 1-877-852-4070 to Express

Scripts. Appeals submitted by mail will not be considered urgent processing unless a subsequent
phone call or fax identifies the appeal as urgent.
Express Scripts completes appeals per business policies that are aligned with state and federal
regulations. Depending on the type of appeal, appeal decisions are by Express Scripts’
pharmacist, physician, panel of clinicians, trained prior authorization staff member, or an
independent third-party prescription drug utilization management company.
Level 1 Appeal Decisions and Notifications

Express Scripts will render Level 1 Appeal determinations within the following timeframes:
• Standard pre-service: 15 days.

• Standard post-service: 20 days; and
• Urgent*: 72 hours.
If new information is received and considered or relied upon in the review of the appeal, such
information will be provided to the patient and prescriber together with an opportunity to
respond prior to issuance of any final adverse benefit determination.

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Level 2 Appeal
When a Level 1 Appeal has been denied, a request for a Level 2 Appeal may be submitted by the
participant within 35 days from receipt of notice of the Level 1 Appeal denial. To initiate a Level
2 Appeal, you must request by mail or fax to the appropriate Clinical Coverage or Administrative
Coverage Review Request department.
An urgent Level 2 Appeal may be submitted if in the opinion of the attending provider, the
application of the time periods for making non-urgent care determinations could seriously
jeopardize the life or health of the patient or the patient’s ability to regain maximum function or
would subject the patient to severe pain that cannot be adequately managed without the care
or treatment that is the subject of the claim.
Urgent appeals must be submitted by phone or fax to the appropriate Clinical Coverage or
Administrative Coverage Review Request department (see the Participant Contact Guide
section). Claims and appeals submitted by mail will not be considered for urgent processing
unless a subsequent phone call or fax identifies the appeal as urgent.
Level 2 Appeal Decisions and Notifications

Express Scripts will render Level 2 Appeal determinations within the following timeframes:
• Standard pre-service: 15 days.
• Standard post-service: 30 days; and
• Urgent*: 72 hours.
If new information is received and considered or relied upon in the review of the appeal, such
information will be provided to the patient and prescriber together with an opportunity to
respond prior to issuance of any final adverse determination.
External Reviews
The right to request an independent external review may be available for an adverse benefit
determination involving medical judgement, rescission, or a decision based on medical
information, including determinations involving treatment that is considered experimental and
investigation. Generally, all internal appeal rights must be exhausted prior to requesting an
external review. The external review will be conducted by an independent review organization
with medical experts that were not involved in the prior determination of the claim.
To submit an external review, the request must be mailed or faxed to the independent review
organization (see Participant Contact Guide) within 4 (four) months of the date of the Level 2
Appeal denial. (If the date that is 4 (four) months from that date is a Saturday, Sunday, or a
holiday, the deadline will be the next business day).
Standard External Review: the pharmacy benefit manager will review the external review request
within 5 (five) business days to determine if it is eligible to be forwarded to an independent

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review organization (IRO) and the patient will be notified within 1 (one) business day of the
decision.
If the request is eligible to be forwarded to an IRO, the request will randomly be assigned to an
IRO, and the Appeal information will be compiled and sent to the IRO within 5 (five) business
days of assigning the IRO. The IRO will notify the claimant in writing that it has received the
request for an external review and if the IRO has determined that the claim involves medical
judgement or rescission, the letter will describe the claimant’s right to submit additional
information within 10 business days for consideration to the IRO. Any additional information the
claimant submits to the IRO will also be sent back to the pharmacy benefit manager for
reconsideration. The IRO will review the claim within 45 calendar days from receipt of the request
and will send the claimant, the Plan and the pharmacy benefit manager written notice of its
decision. If the IRO has determined that the claim does not involve medical judgement or
rescission, the IRO will notify the claimant in writing that the claim is ineligible for a full external
review.
Urgent External Review

Once an urgent external review request is submitted, the claim will immediately be reviewed to
determine if it is eligible for an urgent external review. An urgent situation is one where in the
opinion of the attending provider, the application of the time periods for making non-urgent care
determinations could seriously jeopardize the life or health or the ability for the patient to
regarding maximum function or would subject the patient to severe pain that cannot be
adequately managed without the care or treatment that is the subject of the claim.
If the claim is eligible for urgent processing, the claim will immediately be reviewed to determine
if the request is eligible to be forwarded to an IRO, and the claimant will be notified of the
decision. If the request is eligible to be forwarded to an IRO, the request will randomly be
assigned to an IRO and the Appeal information will be compiled and sent to the IRO. The IRO will
review the claim within 72 hours from receipt of the request and will send the claimant written
notice of its decision.

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Coordination of Benefits
Which Benefits are Subject to Coordination?
When Participants have medical, dental or vision coverage from some other source, benefits are
determined using Coordination of Benefits (COB). COB operates so that one of the plans (i.e., the
primary plan) will pay its benefits first. The other plan or policy, (i.e., the secondary plan) may
then provide additional benefits. In no event will the combined benefits of the primary and
secondary plans exceed 100% of the medical or dental allowable expenses incurred. Sometimes
the combined benefits that are paid will be less than the total expenses.
Participants must let the Plan Administrator, or its designee, know about other coverages when
submitting a claim. If the PEBP Plan is secondary coverage, the Participant will be required to
meet their PEBP Plan Year medical and dental deductibles. This Plan’s prescription drug benefit
does not coordinate benefits for prescription medications, or any covered over the counter (OTC)
medications, obtained through retail or home delivery pharmacy programs. There will be no
coverage for prescription drugs under this Plan if a Participant has additional prescription drug
coverage that is primary.
For the purposes of this COB section, the word “plan” refers to any group or individual medical
or dental policy, contract, or plan, whether insured or self-insured, that provides benefits payable
for medical or dental services incurred by the covered individual either on an individual basis or
as part of a group of employees, retirees or other individuals.
A Participant in a fully insured plan seeking to obtain payment of benefits shall follow and be
bound by the COB procedures under such fully insured plan and the rules and procedures
described in such fully insured plan’s applicable Summary of Insurance.
A Participant in a self-insured plan seeking to obtain payment of benefits shall follow and be
bound by the COB procedures set forth herein. PEBP delegates to the third-party administrator
of such self-insured plan the duty to administer and interpret the COB provisions of this
document and to adopt, document and communicate any rules and procedures necessary or
appropriate to implement the COB procedures, as set forth below.
Which Plan Pays First: Order of Benefit Determination Rules

PEBP uses the order of benefit determination rules established by the National Association of
Insurance Commissioners (NAIC), which are commonly used by insured and self-insured plans.
Any plan that does not use these same rules always pays its benefits first.
When two plans cover the same person, the following order of benefit determination rules
establish which plan is the primary plan (pays first) and which is the secondary plan (pays second).
If the first of the rules does not establish a sequence or order of benefits, the next rule is applied,
and so on, until an order of benefits is established.
These rules are:

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Rule 1: Non-Dependent/Dependent
The plan that covers a person other than as a dependent (e.g., as an employee, retiree, member,
or subscriber) is primary and the plan that covers the person as a dependent is secondary. There
is one exception to this rule. If the person is also a Medicare beneficiary, and as a result of the
provisions of Title XVIII of the Social Security Act and implementing regulations (the Medicare
rules), Medicare is:
• Secondary to the plan covering the person as a dependent;
• Primary to the plan covering the person as other than a dependent (that is, the plan
covering the person as a retired employee);
• Then the order of benefits is reversed, so that the plan covering the person as a
dependent will pay first; and the plan covering the person other than as a dependent
(e.g., as a retired employee) pays second.
This rule applies when both spouses are employed and cover each other as dependents under
their respective plans. The plan covering the person as an employee pays first, and the plan
covering the same person as a dependent will pay benefits second.
Rule 2: Dependent Child Covered Under More Than One Plan

The plan that covers the parent whose birthday falls earlier in the calendar year pays first; the
plan that covers the parent whose birthday falls later in the calendar year pays second, if:
• The parents are married;
• The parents are not separated (whether they ever have been married); or
• A court decree awards joint custody without specifying that one parent has the
responsibility to provide health care coverage for the child.
• If both parents have the same birthday, the plan that has covered one of the parents for
a longer period pays first, and the plan that has covered the other parent for the shorter
period of time pays second.
• The word “birthday” refers only to the month and day in a calendar year; not the year in
which the person was born.
If the specific terms of a court decree state that one parent is responsible for the child’s health
care expenses or health care coverage, and the plan of that parent has actual knowledge of the
terms of that court decree, that plan pays first. If the parent with financial responsibility has no
coverage for the child’s health care services or expenses, but that parent’s current spouse does,
the plan of the spouse of the parent with financial responsibility pays first. However, this
provision does not apply during any plan year during which any benefits were actually paid or
provided before the plan had actual knowledge of the specific terms of that court decree.
If the parents are not married, or are separated (whether they ever were married), or are
divorced, and there is no court decree allocating responsibility for the child’s health care services
or expenses, the order of benefit determination among the plans of the parents and their spouses
(if any) is:
• The plan of the custodial parent pays first; and
• The plan of the spouse of the custodial parent pays second; and

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• The plan of the non-custodial parent pays third; and

• The plan of the spouse of the non-custodial parent pays last.
Rule 3: Retired Employee

The plan that covers a person, as a retired employee or as a retired employee’s dependent pays
second. 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 is ignored.
If a person is covered as a retired employee under one plan and as a dependent of an active
employee under another plan, the order of benefits is determined by Rule (1) Non-
Dependent/Dependent rather than by this rule.
Rule 4: Continuation Coverage
If a person whose coverage is provided under a right of continuation under federal or state law
is also covered under another plan, the plan that covers the person as an employee, retiree,
member, or subscriber (or as that person’s dependent) pays first, and the plan providing
continuation coverage to that same person pays second. 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 is ignored.
If a person is covered other than as a dependent (that is, as an employee, former employee,
retiree, member, or subscriber) under a right of continuation coverage under federal or state law
under one plan and as a dependent of an active employee under another plan, the order of
benefits is determined by Rule 1 rather than by this rule.
Rule 5: Longer/Shorter Length of Coverage
If none of the four previous rules determines the order of benefits, the plan that covered the
person for the longer period pays first; and the plan that covered the person for the shorter
period of time pays second. The length of time a person is covered under a plan is measured from
the date the person was first covered under that plan.
Administration of COB
To administer COB, the Plan reserves the right to:
• Exchange information with other plans involved in paying claims;
• Require that Participants or Participants’ health care provider(s) furnish any necessary
information;
• Reimburse any plan that made payments this Plan should have made; or
• Recover any overpayment from a Participant’s hospital, physician, dentist, other
health care provider, other insurance company, or a Participant.
If this Plan should have paid benefits that were paid by any other plan, this Plan may pay the
party that made the other payments in the amount the Plan Administrator or its designee
determines to be proper under this provision. Any amounts so paid will be benefits under this
Plan, and this Plan will be fully discharged from any liability it may have to the extent of such
payment.
This Plan follows the customary COB rule that the medical program coordinates with only other
medical plans or programs (and not with any dental plan or program), and the dental program

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Appeals
coordinates only with other dental plans or programs (and not with any other medical plan or
program). Therefore, when this Plan is secondary, it will pay secondary medical benefits only
when the coordinating primary plan provides medical benefits, and it will pay secondary dental
benefits only when the primary plan provides dental benefits.
If this Plan is primary, and if the coordinating secondary plan is a health maintenance organization
(HMO), Exclusive Provider Organization (EPO) or other plan that provides benefits in the form of
services, this Plan will consider the reasonable cash value of each service to be both the allowable
expense and the benefits paid by the primary plan. The reasonable cash value of such a service
may be determined based on the prevailing rates for such services in the community in which
the services were provided.
If this Plan is secondary, and if the coordinating primary plan does not cover health care services
because they were obtained out-of-network, benefits for services covered by this Plan will be
payable by this Plan subject to the rules applicable to COB, but only to the extent they would
have been payable if this Plan were the primary Plan.
If this Plan is secondary, and if the coordinating plan is also secondary because it provides by its
terms that it is always secondary or excess to any other coverage, or because it does not use the
same order of benefit determination rules as this Plan, this Plan will not relinquish its secondary
position. However, if this Plan advances an amount equal to the benefits it would have paid had
it been the primary plan, this Plan will be subrogated to rights the Participant may have against
the other plan, and the Participant must execute any documents required or requested by this
Plan to pursue any claims against the other plan for reimbursement of the amount advanced by
this Plan.
This Plan does not coordinate pharmacy benefits when PEBP is the secondary or tertiary payor.
Coordination with Medicare

Coordination with Medicare is not applicable for retirees and their dependents who are eligible
for Medicare Part A and Medicare Part B and who are required to transition to the Medicare
Exchange. The Enrollment and Eligibility Master Plan Document includes information regarding
enrollment in the Medicare Exchange.
Entitlement to Medicare Coverage

When a Participant reaches Medicare eligible age, the Participant must enroll in the Medicare
plan for which the Participant is eligible. Generally, anyone age 65 years or older is entitled to
Medicare Part A and Medicare Part B coverage. Anyone under age 65 years who is entitled to
Social Security Disability Income Benefits is also entitled to Medicare coverage after a waiting
period.
When the Participant Is Not Eligible for Premium Free Medicare Part A
This Plan will pay as primary for services that would have been covered by Part A when a
Participant is not eligible for Premium Free Medicare Part A. However, a Participant must enroll
in Medicare Part B and PEBP will be the secondary payer for Medicare Part B services. This Plan
will always be secondary to Medicare Part B, whether or not a Participant has enrolled. This Plan

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will assume that Medicare has paid 80% of Medicare Part B eligible expenses. This Plan will only
consider the remaining 20% of Medicare Part B expenses.
Coverage Under Medicare and This Plan When a Participant has End-Stage Renal Disease (ESRD)
If, while actively employed, a Participant becomes entitled to Medicare because of end-stage
renal disease (ESRD), this Plan pays first and Medicare pays second for 30 months starting the
earlier of the month in which Medicare ESRD coverage begins, or the first month in which the
individual receives a kidney transplant. Then, starting with the 31st month after the start of
Medicare coverage or the first month after the individual receives a kidney transplant, Medicare
pays first, and this Plan pays second.
If a Participant is under age 65 years and receiving Medicare ESRD benefits the Participant will
not be required to transition to PEBP’s Medicare Exchange program. When a Participant reaches
age 65 years, the Participant will be transitioned to the Medicare Exchange in accordance with
PEBP’s eligibility requirements as stated in the Enrollment and Eligibility Master Plan Document.
How Much This Plan Pays When It Is Secondary to Medicare
When the Participant is covered by Medicare Parts A and B and this Plan is secondary to
Medicare, this Plan pays as secondary to Medicare, with the Medicare negotiated allowable fee
taking precedence. If a service is not covered under Medicare but is covered under this Plan, this
Plan will pay as Primary with the Plan’s allowable fee for the service taking precedence.
When the Retiree or the Retiree’s covered Spouse or Domestic Partner is enrolled in Medicare
Part B, this Plan will pay secondary to Medicare Part B.
If eligible Retirees or their covered Spouses or Domestic Partners are not enrolled in Part B, this
Plan will estimate Medicare’s Part B benefit, assuming Part B pays 80% of the eligible expenses.
This Plan will only consider the remaining 20% of Medicare Part B expenses.
When the Participant Enters into a Medicare Private Contract
A Medicare Participant is entitled to enter into a Medicare private contract with certain health
care practitioners under which he or she agrees that no claim will be submitted to or paid by
Medicare for health care services and/or supplies furnished by that health care practitioner. If a
Medicare Participant enters into such a contract this Plan will not pay any benefits for any health
care services and/or supplies the Medicare Participant receives pursuant to it.
Coordination with Other Government Programs
• Medicaid: If a Participant is covered by both this Plan and Medicaid, this Plan pays first,
and Medicaid pays second.
• Tricare: If a Participant or their covered Dependent is covered by this Plan and Tricare
(the program that provides health care services to active or retired armed services
personnel and their eligible Dependents), this Plan pays first, and Tricare pays second. For
an Employee called to active duty for more than 30 days, Tricare is primary, and this Plan
is secondary.
• Veterans Affairs Facility Services: If a Participant receives services in a U.S. Department
of Veterans Affairs Hospital or facility on account of a military service-related illness or
injury, benefits are not payable by the Plan. If a covered individual receives services in a
U.S. Department of Veterans Affairs Hospital or facility on account of any other condition

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that is not a military service-related illness or injury, benefits are payable by the Plan at
the in-network benefit level at the usual and customary charge, only to the extent those
services are medically necessary and are not excluded by the Plan.
• Worker’s Compensation: This Plan does not provide benefits if the expenses are covered
by workers’ compensation or occupational disease law. If a Participant contests the
application of workers’ compensation law for the illness or injury for which expenses are
incurred, this Plan will pay benefits, subject to its right to recover those payments if and
when it is determined that they are covered under a Workers’ Compensation or
occupational disease law. However, before such payment will be made, a Participant must
execute a Subrogation and reimbursement agreement (described in the Third-Party
Liability Section 4.5) that is acceptable to the Plan Administrator or its designee.

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Subrogation and Third-Party Recovery
Subrogation and Third-Party Recovery

Subrogation applies to situations where the Participant is injured, and another person or entity
is or may be responsible, liable, or contractually obligated, for whatever reason, for the payment
of certain damages or claims arising from or related in any way to the Participant’s injury (the
“Injury”). These damages or claims arising from the injury, irrespective of the way they are
categorized, may include, without limitation, medical expenses, pain and suffering, loss of
consortium, and/or wrongful death. The Plan has a right of subrogation irrespective of whether
the damages or claims are paid or payable to the Participant, the Participant’s estate, the
Participant’s survivors, or the Participant’s attorney(s). All payments made by the Plan for which
it claims a right of subrogation are referred to as subrogated payments.
The subrogation provision provides the Plan with a right of recovery for certain payments made
by the Plan, irrespective of fault, or negligence wrongdoing. All payments made by the Plan
relating in any way to the injury may be recovered directly from the other person or from any
judgment, verdict or settlement obtained by the participant in relation to the injury.
The Participant must cooperate fully, always, and provide all information needed or requested
by the Plan to recover payments, execute any papers necessary for such recovery, and do
whatever is necessary or requested to secure and protect the subrogation rights of the Plan. The
Participant’s required cooperation includes, but is not limited to, the following actions, which
must be performed immediately, upon request by the Plan:
(1) Executing an acknowledgment form or other document acknowledging and

agreeing to protect the Plan’s right of subrogation.
(2) Cooperating and participating in the Plan’s recovery efforts, including but not
limited to participating in litigation commenced or pursued by the Plan or its
Board; and
(3) Filing a claim or demand with another insurance company, including but not
limited to the Participant’s own first party insurance policy or another person’s or
entity’s insurance policy.
Refer to the separate Health and Welfare Benefits Wrap Plan document available at
https://pebp.nv.gov/ for more information regarding third-party liability and subrogation.

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Participant Contact Guide

Public Employees’ Benefits Program (PEBP) Plan Administrator
3427 Goni Road, Ste 109 • Enrollment and eligibility
Carson City, NV 89706 • COBRA information and premium
Customer Service: payments
(775) 684-7000, (702) 486-3100, or (800) • Level 2 claim appeals
326-5496
• External review coordination
Fax: (775) 684-7028
https://pebp.nv.gov/
UMR Third-party Claims Administrator/Third-
Claims Submission party Administrator/PPO Network/ Disease
P O Box 30541 Management Administrator
Salt Lake City, UT 84130-0541 • Claim submission
EDI #39026 • Claim status inquiries
Appeal of Claims • Level 1 claim appeals
P O Box 30546 • Verification of eligibility
Salt Lake City, UT 84130-0546 • Plan Benefit Information
Customer Service • CDHP & Dental only ID Cards
(888) 763-8232 • Obesity Care Management Program
www.UMR.com • Disease Care Management Program
Diabetes Care Management form submission • Sierra Health-Care Options (SHO) –
UMR Southern Nevada PPO Network
27 Corporate Hill Drive • UnitedHealthcare Choice Plus – Outside of
Little Rock, AR 77205 Fax: 800-458-0701 Southern Nevada PPO Network
Email: diabetes@UMR.com • Behavioral Health-Care Options (BHO) –
Behavioral Health Network in Nevada
Sierra Health-Care Options, Inc Utilization Management and Case

PO BOX 15645 Management Company
Las Vegas, NV 89144-5648 • Pre-Certification/Prior Authorization
Customer Service : 888-323-1461 • Utilization Management
Fax : 800-288-2264 • Case Management
• Transplants

131

Express Scripts Pharmacy Pharmacy Benefit Manager for the CDHP, LD
PPO Plan, and EPO Plan
Customer Service • Prescription drug information
(855) 889-7708 • Retail network pharmacies
www.Express-Scripts.com • Prior authorization
• Price a Medication tool
Accredo Patient Customer Service: • Home Delivery service and Mail Order
(800) 803-2523 forms
Accredo Physician Service Line • Preferred Mail Order for diabetic supplies
(800) 987-4904 option 5 • Accredo Specialty Drug Services
• Coverage and Clinical reviews
Express Scripts / Accredo Prior Authorization • Appeals
(800) 753-2851 • External Review Requests
Electronic option: express-scripts.com/PA • Copay/Deductible/Coinsurance assistance
Specialty Medication SaveonSP copay

assistance
(800) 683-1074
www.saveonsp.com/pebp
HSA Bank HSA and HRA Claims Administrator

HRA Claim Submission • HSA/HRA Claims and claim appeals
PO Box 2744
Fargo, ND 58108-2744
hsaforms@hsabank.com
Fax: 855-764-5689
www.hsabank.com
Customer Service: 833-228-9364
askus@hsabank.com
myaccounts.hsabank.com
Diversified Dental Services PPO Dental Network

5470 Kietzke Lane, Ste 300 • Statewide PPO Dental Providers
Reno, NV 89511 • Dental Provider directory
ProviderRelations@ddsppo.com • National PPO Dental Providers outside of
1-866-270-8326 Nevada utilizes the Principal Dental
diversifieddental.com Network
Health Plan of Nevada Southern Nevada Health Maintenance
(702) 242-7300 or (877) 545-7378 Organization (HMO)
www.myhpnstateofnevada.com/ • Medical claims/provider network

132

VIA Benefits Medicare Exchange and Medicare HRA
10975 Sterling View Drive, Suite A1 administrator
South Jordan, UT 84095 • Medigap (Supplemental) plans
(888)598-7545 • Medicare Advantage Plans (HMO and
https://my.viabenefits.com/pebp PPO)
Phone: (888) 598-7545 • HRA claims administrator
Fax: (402) 231-4310
United Healthcare Specialty Benefits • Basic Life Insurance for eligible active and
Group Number: 370074 retirees
Customer Service: 1-888-763-8232 • Member Assistance Program
UnitedHealthcare Specialty Benefits • Global Travel Assistance
P.O. Box 7149
Portland, ME 04112-7149
Office for Consumer Health Assistance Consumer Health Assistance
7150 Pollock Dr • Concerns and problems related to
Las Vegas, NV 89119 coverage
Customer Service: • Provider billing issues
(702) 486-3587 or (888) 333-1597 • External review information
https://adsd.nv.gov/Programs/CHA/Office_fo
r_Consumer_Health_Assistance_(OCHA)/
Corestream PEBP+ Voluntary Benefits Administrator
PEBP+ Customer Care: (775) 249-0716 • Accident Insurance
E-mail: pebpcustomercare@corestream.com • Auto Insurance
www.corestream.com • Critical Illness
• Disability Insurance (Long-term and Short-
Voluntary Life, Critical Illness, Accident, and term)
Hospital Indemnity Insurance • Home Insurance
The Standard Insurance Company • Hospital Indemnity
(888) 288-1270 • Identity Theft
www.standard.com/mybenefits/nevada • Legal Services
• Life Insurance (Supplemental)
• Pet Insurance
• Vision Care

133
Key Terms and Definitions

The following terms or phrases are used throughout this MPD. These terms or phrases have the
following meanings. These terms and definitions do not, and should not be interpreted to, extend
coverage under the Plan.
Accident: A sudden and unforeseen event that is not work-related, resulting from an external or
extrinsic source.
Active Rehabilitation: refers to therapy in which a patient, who can learn and remember, actively
participates in the rehabilitation that is intended to provide significant and measurable
improvement of an individual who is restricted and cannot perform normal bodily function.
Actively Engaged:
• Participation in regular office visits with your provider. The frequency of the office
visits will be determined by your provider who will in turn report this information
to the third-party administrator for monitoring.
• Consistently demonstrating a commitment to weight loss by adhering to the
weight loss treatment plan developed by your weight loss provider including but
not limited to routine exercise, proper nutrition and diet, and pharmacotherapy if
prescribed. Commitment to your weight loss treatment will be measured by the
third-party administrator who will review monthly progress reports submitted by
the provider; and
• Losing weight at a rate determined by the weight loss provider.
Activities of Daily Living: Activities performed as part of a person’s daily routine, such as getting
in and out of bed, bathing, dressing, feeding, or eating, use of the toilet, ambulating, and taking
drugs or medicines that can be self-administered.
Acupuncture: A technique for treating disorders of the body by passing long thin needles through
the skin. This technique is based on the belief that physical illness and disorders are caused by
imbalances in the life force, called Qi, which flows through the body along meridians or channels,
and that the needles stimulate the natural healing energy flow.
When benefits for the services of an acupuncturist are payable by this Plan, the acupuncturist
must be properly licensed by the state in which he or she is practicing and must be performing
services within the scope of that license, or, where licensing is not required, be certified by the
National Certification Commission for Acupuncturists (NCCA).
Adverse Benefit Determination: Means a determination by a health carrier or utilization review

organization that an admission, availability of care, continued stay or other health care service
that is a covered benefit has been reviewed and, based upon the information provided, does not
meet the health carrier’s requirements for medical necessity, appropriateness, health care

134
setting, level of care or effectiveness, and the requested service or payment for the service is
therefore denied, reduced or terminated.
Air Ambulance: A medical transport by a rotary wing air ambulance, as defined in 42 CFR 414.605,
or fixed wing air ambulance, as defined in 42 CFR 414.605, for patients.
Allogenic: Refers to transplants of organs, tissues, or cells from one person to another person.
Heart Transplants are always Allogenic.
Allowable Expenses: The Maximum Allowable Charge for any medically necessary, eligible item
of expense, at least a portion of which is covered under the Plan. When some other non-Medicare
plan pays first in accordance with the application to benefit determinations provision in the
Coordination of Benefits section, this Plan’s allowable expenses shall in no event exceed the other
non-Medicare plan’s allowable expenses.
When some other non-Medicare plan provides benefits in the form of services rather than cash
payments, the Plan Administrator shall assess the value of each service rendered, by determining
the amount that would be payable in accordance with the terms of the Plan, shall be deemed to
be the benefit. Benefits payable under any other non-Medicare plan include the benefits that
would have been payable had claim been duly made.
Ambulance: A vehicle or boat that is licensed or certified for emergency patient transportation
by the jurisdiction in which it operates.
Ambulatory Surgical Facility/Center: A specialized facility that is established, equipped,

operated, and staffed primarily for performing surgical procedures and which fully meets one of
the following two tests:
• It is licensed as an ambulatory surgical facility/center by the regulatory authority

responsible for the licensing under the laws of the jurisdiction in which it is
located; or
Where licensing is not required, it meets all the following requirements:

• It is operated under the supervision of a licensed physician who is devoting full
time to supervision and permits a surgical procedure to be performed only by a
duly qualified physician who, at the time the procedure is performed, is privileged
to perform the procedure in at least one hospital in the area.
• It requires in all cases, except those requiring only local infiltration anesthetics,
that a licensed anesthesiologist administer the anesthetic or supervise an
anesthetist who is administering the anesthetic, and that the anesthesiologist or
anesthetist remain present throughout the surgical procedure.
• It provides at least one operating room and at least one post-anesthesia recovery
room.

135
• It is equipped to perform diagnostic x-ray and laboratory examinations or has an

arrangement to obtain these services.
• It has trained personnel and necessary equipment to handle emergency
situations.
• It has immediate access to a blood bank or blood supplies.
• It provides the full-time services of one or more registered graduate nurses (RNs)
for patient care in the operating rooms and in the post-anesthesia recovery room;
and
• It maintains an adequate medical record for each patient, which contains an
admitting diagnosis (including, for all patients except those undergoing a
procedure under local anesthesia, a preoperative examination report, medical
history, and laboratory tests and/or x-rays), an operative report and a discharge
summary.
An ambulatory surgical facility/center that is part of a hospital, as defined in this section, will be
considered an ambulatory surgical facility/center for the purposes of this Plan.
Ancillary Services/Charges: Charges for services provided by a hospital or other facility other
than room and board, including (but not limited to) use of the operating room, recovery room,
intensive care unit, etc., and laboratory and x-ray services, drugs and medicines, and medical
supplies provided during confinement.
Ancillary services, for purposes of the No Surprises Act, are, with respect to an in-
networkhealth care facility:
Items and services related to emergency medicine, anesthesiology, pathology,
radiology, and neonatology, whether provided by a physician or non-physician
practitioner,
Items and services provided by assistant surgeons, hospitalists, and intensivists;
Diagnostic services, including radiology and laboratory services and subject to
exceptions specified by the Secretary; and
Items and services provided by an out-of-network provider if there is no in-network
provider who can furnish such item or service at such facility.
Anesthesia: The condition produced by the administration of specific agents (anesthetics) to

render the patient unconscious and without conscious pain response (e.g., general anesthesia),
or to achieve the loss of conscious pain response and/or sensation in a specific location or area
of the body (e.g., regional, or local anesthesia). Anesthetics are commonly administered by
injection or inhalation.
Annual/Annually: For the purposes of this Plan, annual and annually refers to the 12-month
period starting July 1 through June 30.
Appliance (Dental): A device to provide or restore function or provide a therapeutic (healing)

effect.

136
Appropriate: See the definition of medically necessary for the definition of appropriate as it
applies to medical services that are medically necessary.
Approved Clinical Trial: A phase I, II, III, or IV trial if it is conducted for the prevention, detection,
or treatment of cancer or another disease or condition likely to lead to death unless the course
of the disease or condition is interrupted.
An Approved Clinical Trial’s study must be:

(1) approved or funded by one or more of:
(a) the National Institutes of Health (NIH),
(b) the Centers for Disease Control and Prevention (CDC),
(c) the Agency for Health Care Research and Quality (AHCRQ),
(d) the Centers for Medicare and Medicaid Services (CMS),
(e) a cooperative group or center of the NIH, CDC, AHCRQ, CMS, the
Department of Defense (DOD), or the Department of Veterans Affairs (VA),
(f) a qualified non-governmental research entity identified by NIH guidelines
for grants; or
(g) the VA, DOD, or Department of Energy (DOE) if the study has been reviewed
and approved through a system of peer review that the Secretary of HHS
determines is comparable to the system used by NIH and assures unbiased
review of the highest scientific standards by qualified individuals who have
no interest in the outcome of the review;
(2) a study or trial conducted under an investigational new drug application reviewed
by the Food and Drug Administration (FDA); or
(3) a drug trial that is exempt from investigational new drug application requirements.
Assistant Surgeon: A medically qualified doctor who assists the surgeon of record perform a
procedure.
Autism Spectrum Disorder: 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.
Autologous: Refers to transplants of organs, tissues, or cells from one part of the body to
another. Bone marrow and skin transplants are often autologous.
Average Wholesale Price (AWP): The average price at which drugs are purchased at the
wholesale level.
Bariatric Surgery Center of Excellence: A provider that has met the requirements outlined by
the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
and is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement
Program (MBSAQIP).

137
Base Plan: The self-funded Consumer Driven Health Plan (CDHP); the base plan is also defined as
the “default plan” where applicable in this document and other materials produced by PEBP.
Behavioral Health Disorder: Any illness that is defined within the mental disorders section of the
current edition of the International Classification of Diseases (ICD) manual or is identified in the
current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including a
psychological and/or physiological dependence on or addiction to alcohol or psychiatric drugs or
medications regardless of any underlying physical or organic cause.
Behavioral health disorders covered under this Plan may include, but are not limited to
depression, schizophrenia, and substance abuse and treatment that primarily uses
psychotherapy or other psychotherapist methods and is provided by behavioral health
practitioners as defined in this section. Certain behavioral health disorders, conditions and
diseases are specifically excluded from coverage as noted in the Benefit Limitations and
Exclusions section.
Behavioral Health Practitioner: A psychiatrist, psychologist, or a mental health or substance

abuse counselor or social worker who has a master’s degree, or other provider who is legally
licensed and/or legally authorized to practice or provide service, care, or treatment of behavioral
health disorders under the laws of the state or jurisdiction where the services are rendered; and
acts within the scope of his or her license.
Behavioral Health Treatment: Services, including room and board, given by a behavioral health
treatment facility or area of a hospital that provides behavioral or mental health or substance
abuse treatment for a mental disorder identified in the current edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM). If there are multiple diagnoses, only the treatment
for the illness that is identified under the DSM code is considered a behavioral health treatment
for the purposes of this Plan.
Behavioral Health Treatment Facility: A specialized facility that is established, equipped,

operated, and staffed primarily for providing a program for diagnosis, evaluation, and effective
treatment of behavioral health disorders and which fully meets one of the following two tests:
• It is licensed as a behavioral health treatment facility by the regulatory authority
having responsibility for the licensing under the laws of the jurisdiction in which it
is located; or
• Where licensing is not required, it meets all the following requirements: has at
least one physician on staff or on call and provides skilled nursing care by licensed
nurses under the direction of a full-time registered nurse (RN) and prepares and
maintains a written plan of treatment for each patient based on the medical,
psychological, and social needs of the patient.
A behavioral health treatment facility that qualifies as a hospital is covered by this Plan as a
hospital and not a behavioral health treatment facility. A transitional facility, group home,

138
halfway house or temporary shelter is not a behavioral health treatment facility under this Plan
unless it meets the requirements above in the definition of behavioral health treatment facility.
Benefit, Benefit Payment, Plan Benefit: The amount of money payable for a claim, based on the
usual and customary charge, subject to the Plan’s Maximum Allowable Charge, or negotiated fee
schedule, after calculation of all Deductibles, Coinsurance, and copayments, and after
determination of the Plan’s exclusions, limitations, and maximums.
Birth (or Birthing) Center: A specialized facility that is primarily a place for delivery of children
following a normal uncomplicated pregnancy and which fully meets one of the two following
tests:
• It is licensed by the regulatory authority having responsibility for the licensing
under the laws of the jurisdiction in which it is located; or
• Where licensing is not required, it meets all the following requirements:
• It is operated and equipped in accordance with any applicable state law for
providing prenatal care, delivery, immediate post-partum care, and care of a child
born at the center.
• It is equipped to perform routine diagnostic and laboratory examinations,
including (but not limited) to hematocrit and urinalysis for glucose, protein,
bacteria and specific gravity, and diagnostic x-rays, or has an arrangement to
obtain those services.
• It has available to handle foreseeable emergencies, trained personnel, and
necessary equipment, including (but not limited to) oxygen, positive pressure
mask, suction, intravenous equipment, equipment for maintaining infant
temperature and ventilation, and blood expanders.
• It provides at least two beds or two birthing rooms.
• It is operated under the full-time supervision of a licensed physician, registered
nurse (RN) or certified nurse midwife.
• It has a written agreement with at least one hospital in the area for immediate
acceptance of patients who develop complications.
• It has trained personnel and necessary equipment to handle emergency
situations.
• It has immediate access to a blood bank or blood supplies.
• It has the capacity to administer local anesthetic and to perform minor surgery.
• It maintains an adequate medical record for each patient that contains prenatal
history, prenatal examination, any laboratory or diagnostic tests and a post-
partum summary.
• It is expected to discharge or transfer patients within 48 hours following delivery.
A birth (or birthing) center that is part of a hospital, as defined in this section, will be a birth (or
birthing) center for the purposes of this Plan.
Business Day: Refers to all weekdays, except Saturday or Sunday, Nevada holiday, or federal
holiday.

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Case Management: A process administered by the UM company in which its medical

professionals work with the patient, family, caregivers, providers, Claims Administrator,
Pharmacy Benefit Manager and PEBP to coordinate a timely and cost-effective treatment
program. Case management services are particularly helpful when the patient needs complex,
costly, and/or high-technology services, and when assistance is needed to guide patients through
a maze of potential providers.
Cardiac Rehabilitation: Cardiac Rehabilitation refers to a formal program of controlled exercise

training and cardiac education under the supervision of qualified medical personnel capable of
treating cardiac emergencies, as provided in a hospital outpatient department or other
outpatient setting. The goal is to advance the patient to a functional level of activity and exercise
without cardiovascular complications to limit further cardiac damage and reduce the risk of
death. Patients are to continue at home the exercise and educational techniques they learn in
this program. Cardiac rehabilitation services are payable for patients who have had a heart attack
(myocardial infarction) or open-heart surgery.
Certified Surgical Assistant: A person who does not hold a valid health care license as an RN,
Nurse Practitioner (NP), Physician Assistant (PA), Podiatrist, Dentist, MD or DO, who assists the
primary surgeon with a surgical procedure in the operating room and who bills, commonly as an
assistant surgeon, and who acts within the scope of his/her license or certification. Such
individuals are payable by this Plan, including but not limited to designation as a Certified Surgical
Assistant (CSA), Certified Surgical Technologist (CST), Surgical Technologist (ST), Certified
Technical Assistant (CTA), or Certified Operating Room Technician (CORT).
Chemical Dependency: This is another term for Substance Abuse. (See also the definitions of
Behavioral Health Disorders and Substance Abuse).
Child(ren): See the definition of Dependent Child(ren).
Chiropractor: A person who holds the degree of Doctor of Chiropractic (DC) and is legally licensed
and authorized to practice the detection and correction, by mechanical means, of the
interference with nerve transmissions and expressions resulting from distortion, misalignment,
or dislocation of the spinal column (vertebrae); and who acts within the scope of his or her
license.
Chiropractic Services: PEBP considers chiropractic services to be medically necessary when all
the following criteria are met:
• participant has objective medical findings of a neuro-musculoskeletal disorder;
and
• a clearly defined treatment plan has been established including treatment and
discharge goals; and
• services are not for maintenance purposes.

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Christian Science Practitioner: Christian Science is a system of religious teaching based on an

interpretation of scripture, founded in 1866 by Mary Baker Eddy. It emphasizes full healing of
disease by mental and spiritual means. Certain members of the Christian Science church are
designated as Christian Science Practitioners who counsel and assist church members in mental
and spiritual means to overcome illness based on Christian Science teachings.
Chronic Medication Synchronization: “Chronic medication” means any drug that is prescribed to
treat any disease or other condition which is determined to be permanent, persistent, or lasting
indefinitely. “Synchronization” means the alignment of the dispensing of multiple medications
by a single contracted pharmacy for improving a patient’s adherence to a prescribed course of
medication. This includes providing coverage for less than a 30-day supply to enable synchronization.
Claims Administrator: The person or company retained by the Plan to administer claim payment
responsibilities and other administration or accounting services as specified by the Plan.
Clinical Trials: See Experimental and Investigational in the Key Terms and Definitions section.
Coinsurance: That portion of Eligible Medical Expenses for which the covered person has financial
responsibility. In most instances, the covered individual is responsible for paying a percentage of
covered medical expenses more than the Plan’s Deductible. The Coinsurance varies depending
on whether In-Network or Out-of-Network providers are used.
Complications of Pregnancy: Any condition that requires hospital confinement for medical
treatment, and if the pregnancy is not terminated, is caused by an injury or sickness not directly
related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed
abortion or similar medically diagnosed conditions; or, any condition that requires hospital
confinement and if the pregnancy is terminated, results in non-elective cesarean section, ectopic
pregnancy or spontaneous termination.
Compound Drugs: Any drug that has more than one ingredient and at least one of them is a
Federal Legend Drug or a drug that requires a prescription under state law.
Concierge Medicine: Is a relationship between a patient and a primary care physician or dentist
in which the patient usually pays an annual or monthly fee or retainer to receive easier access to
a primary care provider or dentist. Concierge medicine usually means that the patient will
experience quicker scheduling of appointments, limited or no waiting times, longer and more
thorough examinations and coordination of all medical or dental care. Other terms in use include
boutique medicine, retainer-based medicine, and innovative medical practice design. The
practice is also referred to as membership medicine, concierge health care, cash only practice,
direct care, direct primary care, and direct practice medicine. Most concierge medicine practices
do not bill insurance.
Concurrent Review: A managed care program designed to assure that hospitalization and health
care facility admissions and length of stay, surgery and other health care services are medically
necessary by having the utilization management company conduct ongoing assessment of the

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health care as it is being provided, especially (but not limited to) inpatient confinement in a
hospital or health care facility.
Continuing Care Patient: An individual who, with respect to a provider or facility:

• is undergoing a course of treatment for a serious and complex condition from the provider
or facility;
• is undergoing a course of institutional or inpatient care from the provider or facility;
• is scheduled to undergo non-elective surgery from the provider, including receipt of
postoperative care from such provider or facility with respect to such a surgery;
• is pregnant and undergoing a course of treatment for the pregnancy from the provider or
facility; or
• is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the
Social Security Act) and is receiving treatment for such illness from such provider or facility.
Convalescent Care Facility: See the definition of Skilled Nursing Facility.
Coordination of Benefits (COB): The rules and procedures applicable to the determination of
how Plan benefits are payable when a person is covered by two or more health care plans.
Copayment, Copay: The fixed dollar amount you are responsible for paying when you incur an
eligible medical expense for certain services, generally those provided by network health care
practitioners, hospitals (or emergency rooms of hospitals), or health care facilities. This can be in
addition to Coinsurance amounts due on the same incurred charges. Copayments are limited to
certain benefits under this program.
Corrective Appliances: The general term for appliances or devices that support a weakened body
part (orthotic) or replace a missing body part (prosthetic). To determine the category of any item,
see also the definitions of Durable Medical Equipment, Nondurable Supplies, Orthotic Appliance
(or device) and Prosthetic Appliance (or device).
Cosmetic Surgery or Treatment: Surgery or medical treatment to improve or preserve physical

appearance, but not physical function. Cosmetic surgery or treatment includes medical, dental,
or surgical treatment intended to restore or improve physical appearance, as determined by the
Plan Administrator, UM company, or its designee.
Cost-Efficient: See the definition of medically necessary for the definition of cost-efficient as it
applies to medical services that are medically necessary.
Cost-Share or Cost Sharing: The amount a participant or beneficiary is responsible for paying for
a covered item or service under the terms of the plan. Cost sharing generally includes
copayments, coinsurance, and amounts paid towards deductibles, but does not include amounts
paid towards premiums, balance billing by out-of-network providers, or the cost of items or
services that are not covered under the plan.

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Cost Sharing Amount for Emergency and Non-emergency Services at PPO Facilities performed by
out-of-network Providers and air ambulance services from out-of-network providers will be
calculated consistent with the federal No Suprises Act.
Covered Individual: Any employee or retiree (as those terms are defined in this Plan), and that
person’s eligible spouse or dependent child who has completed all required formalities for
enrollment for coverage under the Plan and is covered by the Plan.
Covered Medical Expenses: See the definition of Eligible Medical Expenses.
Custodial Care: Care and services given mainly for personal hygiene or to perform the activities
of daily living. Some examples of custodial care are helping patients get in and out of bed, bathe,
dress, eat, use the toilet, walk (ambulate), or take drugs or medicines that can be self-
administered. These services are custodial care regardless of where the care is given or who
recommends, provides, or directs the care. Custodial care can be given safely and adequately (in
terms of generally accepted medical standards) by people who are not trained or licensed
medical or nursing personnel. Custodial care may be payable by this Plan under certain
circumstances, such as when custodial care is provided during a covered hospitalization or during
a covered period of hospice care.
Customary Charge: See the definition of Usual and Customary Charge.
Deductible: The amount of eligible medical, prescription drug and dental expenses you are
responsible for paying before the Plan begins to pay benefits. The dental Deductibles are
discussed in the separate PPO Dental Master Plan Document.
Dental: As used in this document, dental refers to any services performed by (or under the
supervision of) a dentist, or supplies (including dental prosthetics). Dental services include
treatment to alter, correct, fix, improve, remove, replace, reposition, restore or treat teeth; the
gums and tissues around the teeth; the parts of the upper or lower jaws that contain the teeth
(the alveolar processes and ridges); the jaw, any jaw implant, or the joint of the jaw (the
Temporomandibular Joint); bite alignment, or the meeting of upper or lower teeth, or the
chewing muscles; and/or teeth, gums, jaw or chewing muscles because of pain, injury, decay,
malformation, disease or infection. Dental services and supplies coverage is provided in the PPO
Dental Plan (refer to the separate PPO Dental Plan MPD available at https://pebp.nv.gov/) and
are not covered under the medical expense coverage of this Plan unless the medical Plan
specifically indicates otherwise in the Schedule of Benefits.
Dependent: Any of the following individuals: Dependent child(ren), spouse or domestic partner
as those terms are defined in this document.
Dependent Child(ren): For the purposes of this Plan, a dependent child is any of your children
under the age of 26 years, including:
• natural child,

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• child(ren) of a domestic partner,

• stepchild,
• legally adopted child or child placed in anticipation for adoption (the term placed
for adoption means the assumption and retention by the employee of a legal
obligation for total or partial support of the child in anticipation of adoption of the
child and the child must be available for adoption and the legal adoption process
must have commenced),
• child who qualifies for benefits under a QMCSO/NMSN (see the Eligibility section
for details on QMCSO/NMSN), or
• any other person who:
(1) Bears a relationship described in 26 U.S.C. § 152(c)(2) to the participant or his or
her spouse or domestic partner, and
(2) Is unmarried.
Disability: A determination by the Plan Administrator or its designee (after evaluation by a

physician) that a person has a permanent or continuing physical or mental impairment causing
the person to be unable to be self-sufficient as the result of having the physical or mental
impairment such as intellectual disability, cerebral palsy, epilepsy, neurological disorder, or
psychosis.
Domestic Partner: A person whose domestic partnership with another has been legally
registered or recognized as set forth in NRS Chapter 122A.
Drug: See the definition for prescription drug.
• Durable Medical Equipment: Equipment which can withstand repeated use, is primarily
and customarily used for a medical purpose, is generally not useful in the absence of an
injury or illness; is not disposable or non-durable, and is appropriate for the patient’s
home.
Durable medical equipment includes (but is not limited to) apnea monitors, augmentation
devices, blood sugar monitors, commodes, electric hospital beds with safety rails, electric and
manual wheelchairs, nebulizers, oximeters, oxygen and supplies, and ventilators.
Elective Hospital Admission, Service or Procedure: Any non-emergency hospital admission,

service or procedure that can be scheduled or performed at the patient’s or physician’s
convenience without jeopardizing the patient’s life or causing serious impairment of body
function.
Eligible Medical Expenses: Expenses for medical services or supplies, but only to the extent that
they are medically necessary; the charges for them are usual and customary and do not exceed
the Plan’s Maximum Allowable Charge or negotiated fee schedule; coverage for the services or
supplies is not excluded (as provided in the Benefit Limitations and Exclusions section); and the
Plan Year maximum benefits for those services or supplies has not been reached.

144
Emergency: See the definition for Medical Emergency.
Emergency Medical Condition: A medical condition, including mental health condition or

substance use disorder, manifested by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson who possesses an average knowledge of health and medicine
could reasonably expect the absence of immediate medical attention to result in serious
impairment to bodily functions, serious dysfunction of any bodily organ or part, or placing the
health of a woman or her unborn child in serious jeopardy.
Emergency Care: Medical and health services provided for an Emergency Medical Condition as
defined above.
Emergency Services means the following:

• An appropriate medical screening examination that is within the capability of the
emergency department of a hospital or of an independent freestanding emergency
department, as applicable, including ancillary services routinely available to the
emergency department to evaluate such emergency medical condition; and
• Within the capabilities of the staff and facilities available at the hospital or the
independent freestanding emergency department, as applicable, such further medical
examination and treatment as are required to stabilize the patient (regardless of the
department of the hospital in which such further examination or treatment is
furnished).
Emergency Services furnished by an emergency facility (regardless of the department of the
hospital in which such items or services are furnished) also include post stabilization services
(services after the patient is stabilized) and as part of outpatient observation or an inpatient or
outpatient stay related to the emergency medical condition, until:
• The provider or facility determines that the participant or beneficiary is able to travel
using nonmedical transportation or nonemergency medical transportation; or
• The participant or beneficiary is supplied with a written notice, as required by federal
law, that the provider is an out-of-network provider with respect to the Plan, of the
estimated charges for your treatment and any advance limitations that the Plan may put
on your treatment, of the names of any in-network providers at the facility who are able
to treat you, and that you may elect to be referred to one of the in-network providers
listed; and
• The participant or beneficiary gives informed consent to continued treatment by the
out-of-network provider, acknowledging that the participant or beneficiary understands
that continued treatment by the out-of-network provider may result in greater cost to
the participant or beneficiary.
Emergency Surgery: A surgical procedure performed within 24 hours of the sudden and
unexpected severe symptom of an illness, or within 24 hours of an accidental injury causing a
life-threatening situation.

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Employee: Unless specifically indicated otherwise when used in this document, employee refers
to a person employed by an agency or entity that participates in the PEBP program, and who is
eligible to enroll for coverage under this Plan.
Employer: Unless specifically indicated otherwise when used in this document, employer refers
to an agency or entity that participates in the PEBP program, including (but not limited to) most
State agencies, as well as some county and city agencies and organizations.
Enteral Formulas: Specialized liquid nutritional products designed to provide nutrition directly
into the gastrointestinal tract.
Exclusions: Specific conditions, circumstances, and limitations, as set forth in the Benefit
Limitations and Exclusions section for which the Plan does not provide Plan benefits.
Experimental and/or Investigational Services: Coverage for certain treatment received as part
of a clinical trial or study for treatment of cancer or chronic fatigue syndrome will be provided
subject to the requirements and limitations set forth in NRS 695G.173.
Unless mandated by law, the Plan Administrator or its designee has the discretion and authority
to determine if a service or supply is, or should be, classified as experimental and/or
investigational. A service or supply will be deemed to be experimental and/or investigational if,
in the opinion of the Plan Administrator or its designee, based on the information and resources
available at the time the service was performed or the supply was provided, or the service or
supply was considered for precertification under the Plan’s utilization management program, any
of the following conditions were present with respect to one or more essential provisions of the
service or supply:
• The service or supply is described as an alternative to more conventional therapies

in the protocols (the plan for the course of medical treatment that is under
investigation) or consent document (the consent form signed by or on behalf of
the patient) of the health care provider that performs the service or prescribes the
supply.
• The prescribed service or supply may be given only with the approval of an
Institutional Review Board as defined by federal law.
• In the opinion of the Plan Administrator or its designee, there is either an absence
of authoritative medical, dental or scientific literature on the subject, or a
preponderance of such literature published in the United States, and written by
experts in the field, that shows that recognized medical, dental or scientific
experts: classify the service or supply as experimental and/or investigational; or
indicate that more research is required before the service or supply could be
classified as equally or more effective than conventional therapies.
• With respect to services or supplies regulated by the Food and Drug
Administration (FDA), FDA approval is required for the service and supply to be
lawfully marketed; and it has not been granted at the time the service or supply is
prescribed or provided; or a current Investigational new drug or new device

146
application has been submitted and filed with the FDA. However, a drug will not
be considered experimental and/or investigational if it is:
o Approved by the FDA as an “Investigational new drug for treatment use”; or
o Classified by the National Cancer Institute as a Group C cancer drug when used
for treatment of a “life threatening disease,” as that term is defined in FDA
regulations; or
o Approved by the FDA for the treatment of cancer and has been prescribed for
the treatment of a type of cancer for which the drug was not approved for
general use, and the FDA has not determined that such drug should not be
prescribed for a given type of cancer.
o The prescribed service or supply is available to the covered person only
through participation in Phase I or Phase II clinical trials; or Phase III
Experimental or research clinical trials or corresponding trials sponsored by
the FDA, the National Cancer Institute, or the National Institutes of Health.
In determining if a service or supply is or should be classified as experimental and/or

Investigational, the Plan Administrator or its designee will rely only on the following specific
information and resources that are available at the time the service or supply was performed,
provided, or considered for precertification under the Plan’s utilization management program:
• Medical records of the covered person.
• The consent document signed, or required to be signed, to receive the prescribed
service or supply.
• Protocols of the health care provider that renders the prescribed service or
prescribes or dispenses the supply.
• Authoritative peer-reviewed medical or scientific writings that are published in
the United States regarding the prescribed service or supply for the treatment of
the covered person’s diagnosis, including (but not limited to) “United States
Pharmacopoeia Dispensing Information”; and “American Hospital Formulary
Service”.
• The published opinions of the American Medical Association (AMA), such as “The
AMA Drug Evaluations” and “The Diagnostic and Therapeutic Technology
Assessment (DATTA) Program, etc.; or specialty organizations recognized by the
AMA; or the National Institutes of Health (NIH); or the Center for Disease Control
(CDC); or the Office of Technology Assessment; or the American Dental
Association (ADA), with respect to dental services or supplies.
• Federal laws or final regulations that are issued by or applied to the FDA or
Department of Health and Human Services regarding the prescribed service or
supply.
• The latest edition of “The Medicare Coverage Issues Manual.”
NOTE: To determine how to obtain a precertification of any procedure that might be deemed to
be experimental and/or investigational, see Precertification in the Utilization Management
section.

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Explanation of Benefits (EOB): When a claim is processed by the claims administrator you will be
sent a form called an Explanation of Benefits, or EOB. The EOB describes how the claim was
processed, such as allowed amounts, amounts applied to your Deductible, if your out-of-pocket
maximum has been reached, if certain services were denied and why, amounts you need to pay
to the provider, etc.
Extended Care Facility: See the definition of Skilled Nursing Facility.
Expedited Appeal: If a participant appeals a decision regarding a denied request for

precertification (pre-service claim) for an urgent care claim, the participant or participant’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.
External Review: An independent review of an adverse benefit determination conducted by an

external review organization.
External Review Organization: An organization that (1) conducts an external review of a final
adverse benefit determination; and (2) is certified in accordance with regulations adopted by the
Nevada Commissioner of Insurance.
Federal Legend Drugs: Any medicinal substance that the Federal Food, Drug and Cosmetic Act
requires to be labeled, “Caution — Federal Law prohibits dispensing without prescription.”
Food and Drug Administration (FDA): The U.S. government agency responsible for
administration of the Food, Drug and Cosmetic Act and whose approval is required for certain
prescription drugs and other medical services and supplies to be lawfully marketed.
Free-Standing Laboratory Facility: Free-standing laboratory facilities are stand-along facilities

that are not affiliated with a hospital system. Examples of preferred free-standing laboratory
facilities include Labor Corp or Quest.
Formulary: A list of generic and brand name drug products available for use by participants. This
is maintained by the Pharmacy Benefit Manager and may be subject to change according to the
Pharmacy Benefit Manager.
Gender Dysphoria: Distress or impairment in social, occupational or other areas of functioning

caused by a marked difference between the gender identity or expression of a person and the
sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of
the following:
(1) A marked difference between gender identity or expression and primary or secondary sex
characteristics or anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex characteristics because of a marked
difference between such sex characteristics and gender identity or expression or a desire

148
to prevent the development of anticipated secondary sex characteristics in young

adolescents.
(3) A strong desire for the primary or secondary sex characteristics of the gender opposite
from the sex assigned at birth.
(4) A strong desire to be of the opposite gender or a gender different from the sex assigned
at birth.
(5) A strong desire to be treated as the opposite gender or a gender different from the sex
assigned at birth.
(6) A strong conviction of experiencing typical feelings and reactions of the opposite gender
or a gender different from the sex assigned at birth.
Generic; Generic Drug: A prescription drug that has the equivalency of the brand name drug with
the same use and metabolic disintegration. This Plan will consider as a generic drug any FDA
approved generic pharmaceutical dispensed according to the professional standards of a licensed
Pharmacist and clearly designated by the pharmacist as being generic. (See also the Prescription
Drug section of the Schedule of Benefits and the Prescription Drug subsection of the Medical
Exclusion section).
Genetic Counseling: Counseling services provided before or in the absence of genetic testing to
educate the patient about issues related to chromosomal abnormalities or genetically
transmitted characteristics and/or the possible impacts of the results of genetic testing; and
provided after Genetic Testing to explain to the patient and his or her family the significance of
any detected chromosomal abnormalities or genetically transmitted characteristics that indicate
either the presence of or predisposition to a disease or disorder of the individual tested, or the
presence of or predisposition to a disease or disorder in a fetus of a pregnant woman.
Genetic Information: Information regarding the presence or absence of chromosomal

abnormalities or genetically transmitted characteristics in a person that is obtained from genetic
testing, or that may be inferred from a person’s family medical history.
Genetic Testing: Tests that involve the extraction of DNA from an individual’s cells and analysis
of that DNA to detect the presence or absence of chromosomal abnormalities or genetically
transmitted characteristics that indicate the presence of a disease or disorder, the individual’s
predisposition to a disease or disorder, or the probability that the chromosomal abnormality or
characteristic will be transmitted to that person’s child, who will then either have that disease or
disorder, a predisposition to develop that disease or disorder, or become a carrier of that
abnormality or characteristic with the ability to transmit it to future generations. Tests that assist
the health care practitioner in determining the appropriate course of action or treatment for a
medical condition.
Government-Provided Services (Tricare/CHAMPUS, VA, etc.): Expenses for health care services
provided to a covered participant that federal, state, or local law (e.g., Tricare/Champus, VA,
except the Medicaid program), expenses for care required by a public entity and care for which
there would not normally be a charge.

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Health Care Facility: (for non-emergency services) is each of the following:

• A hospital (as defined in section 1861(e) of the Social Security Act);
• A hospital outpatient department;
• A critical access hospital (as defined in section 1861(mm)(1) of the Social Security Act);
and
• An ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security
Act
Health Care Practitioner: A physician, behavioral health practitioner, chiropractor, dentist, nurse,
nurse practitioner, physician assistant, podiatrist, or occupational, physical, respiratory or speech
therapist or speech pathologist, master’s prepared audiologist, optometrist, optician for vision
Plan benefits, oriental medicine doctor for acupuncture or Christian Science Practitioner, or other
provider who is legally licensed and/or legally authorized to practice or provide certain health
care services under the laws of the state or jurisdiction where the services are rendered: and acts
within the scope of his or her license and/or scope of practice.
Health Care Provider: A health care practitioner as defined above, or a hospital, ambulatory
surgical facility, behavioral health treatment facility, birthing center, home health care agency,
hospice, skilled nursing facility, or sub-acute care facility (as those terms are defined in this Key
Terms and Definitions section).
Health Reimbursement Arrangement (HRA): A Health Reimbursement Arrangement (HRA) is an

employer-funded spending account that can be used to pay qualified medical expenses. The HRA
is 100% funded by the employer. The terms of these arrangements can provide first dollar
medical coverage until the funds are exhausted or insurance coverage kicks in. The contribution
amount per employee is set by the employer, and the employer determines what the funds can
be used to cover and if the dollars can be rolled over to the next year. In most cases, if the
employee leaves the employer, they cannot take remaining HRA funds with them.
Health Savings Account (HSA): An account that allows individuals to pay for current health
expenses and save for future qualified medical and Retiree health expenses on a tax-free basis.
HIPAA: Health Insurance Portability and Accountability Act of 1996. Federal regulation affecting
portability of coverage; electronic transmission of claims and other health information; privacy
and confidentiality protections of health information.
HIPAA Special Enrollment: Enrollment rights under HIPAA for certain employees and dependents
who experience a loss of other coverage and when there is an adoption, placement for adoption,
birth, or marriage.
Home Health Care: Intermittent skilled nursing care services provided by a licensed home health
care agency (as those terms are defined in this section).
Home Health Care Agency: An agency or organization that provides a program of Home Health
Care and meets one of the following three tests:

150
• It is approved by Medicare; or
• It is licensed as a home health care agency by the regulatory authority having
responsibility for the licensing under the laws of the jurisdiction in which it is
located; or
• If licensing is not required, it meets all the following requirements:
• It has the primary purpose of providing a home health care delivery system
bringing supportive skilled nursing and other therapeutic services under the
supervision of a physician or registered nurse to the home.
• It has a full-time administrator.
• It is run according to rules established by a group of professional health care
providers including physicians and registered nurses.
• It maintains written clinical records of services provided to all patients.
• Its staff includes at least one registered nurse, or it has nursing care by a registered
nurse available.
• Its employees are bonded.
• It maintains malpractice insurance coverage.
Homeopathy: A school of medicine based on the theory that when large doses of drugs or
substances produce symptoms of an illness in healthy people, administration of small doses of
those drugs or substances will cure the same symptoms. Homeopathy principles are designed to
enhance the body’s natural protective mechanisms based on a theory that “like cures like” or
“treatment by similar.” See also the Exclusions section of this document regarding homeopathic
treatment and services. When the services of homeopaths are payable by this Plan (e.g., an office
visit), the homeopath must be properly licensed to practice homeopathy in the state in which he
or she is practicing and must be performing services within the scope of that license or, where
licensing is not required, have successfully graduated with a diploma of Doctor of Medicine in
Homeopathy from an institution which is approved by the American Institute of Homeopathy
and completed at least 90 hours of formal post- graduate courses or training in a program
approved by the American Institute of Homeopathy.
Hospice: An agency or organization that administers a program of palliative and supportive

health care services providing physical, psychological, social, and spiritual care for terminally ill
persons assessed to have a limited life expectancy. Hospice care is intended to let the terminally
ill spend their last days with their families at home (home hospice services) or in a home-like
setting (inpatient hospice), with emphasis on keeping the patient as comfortable and free from
pain as possible and providing emotional support to the patient and his or her family.
A hospice agency must meet one of the following tests:

• It is approved by Medicare; or is licensed as a hospice agency by the regulatory
authority having responsibility for the licensing under the laws of the jurisdiction in
which it is located; or
• If licensing is not required, it meets all the following requirements:
a. It provides 24-hour-a-day, 7 day-a-week service.
b. It is under the direct supervision of a duly qualified physician.

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c. It has a full-time administrator.

d. It has a nurse coordinator who is a registered nurse with four years of full-
time clinical experience. Two of these years must involve caring for terminally
ill patients.
e. The main purpose of the agency is to provide hospice services.
f. It maintains written records of services provided to the patient.
g. It maintains malpractice insurance coverage.
h. A hospice agency that is part of a hospital will be considered a hospice agency
for the purposes of this Plan.
Hospital: A public or private facility or institution, other than one owned by the U.S Government,
licensed and operating according to law, that:
• Is legally operated in the jurisdiction where it is located.

• Is engaged mainly in providing inpatient medical care and treatment for injury and
illness in return for compensation.
• Has organized facilities for diagnosis and major surgery on its premises.
• Is supervised by a staff of at least two physicians.
• Has 24-hour-a-day nursing service by registered nurses; and
• Is not a facility specializing in dentistry; or an institution which is mainly a rest
home; a home for the aged; a place for drug addicts; a place for alcoholics; a
convalescent home; a nursing home; an extended care or skilled nursing facility or
similar institution; or a Long-Term Acute Care Facility (LTAC).
A hospital may include facilities for behavioral health treatment that are licensed and operated
according to law. Any portion of a hospital used as an ambulatory surgical facility, birth (or
birthing) center, hospice, skilled nursing facility, sub-acute care facility, or other place for rest,
custodial care, or the aged shall not be regarded as a hospital for any purpose related to this Plan.
Illness: Any bodily sickness or disease, including any congenital abnormality of a newborn child,
as diagnosed by a physician, and as compared to the person’s previous condition. Pregnancy of
a covered employee or covered spouse will be an illness only for coverage under this Plan.
However, infertility is not an illness for coverage under this Plan.
Independent Freestanding Emergency Department: A health-care facility (not limited to those

described in the definition of health care facility) that is geographically separate and distinct from
a hospital under applicable State law and provides Emergency Services.
Inherited Metabolic Disorder: A genetically acquired disorder of metabolism involving the

inability to properly metabolize amino acids, carbohydrates, or fats, as diagnosed by a physician
using standard blood, urine, spinal fluid, tissue, or enzyme analysis. Inherited Metabolic Disorders
are also referred to as inborn errors of metabolism and include Phenylketonuria (PKU), Maple
Syrup Urine Disease, Homocystinuria and Galactosemia. Lactose intolerance without a diagnosis

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of Galactosemia is not an Inherited Metabolic Disorder under this Plan. See Special Food
Products.
Injury: Any damage to a body part resulting from trauma from an external source.
Injury to Teeth: An injury to the teeth caused by trauma from an external source. This does not
include an injury to the teeth caused by any intrinsic force, such as the force of biting or chewing.
Benefits for injury to sound and natural teeth are payable under the medical Plan.
In-Network Provider: Means an In-Network provider that the network or one of its rental
networks have contracted with or have arrangements with to provide health services to covered
individuals. An In-Network provider has agreed to charge participants a discounted rate. To
determine if a provider is an In-Network provider log on to https://pebp.nv.gov/. You may also
call the number on the back of your ID card and a customer service representative can help you
locate an In-Network provider.
In-Network Services: Services provided by a health care provider that is a member of the Plan’s
Preferred Provider Organization (PPO), as distinguished from Out-of-Network services that are
provided by a health care provider that is not a member of the PPO network.
In-Network Contracted Rate: The negotiated amount determined by the PPO network to be the
maximum amount charged by the PPO provider for a covered service. In some cases, the In-
Network contracted amount may be applied to Out-of-Network provider charges.
Inpatient Services: Services provided in a hospital or other health care facility during the period
when charges are made for room and board.
Intensive Care Unit: A section, ward, or wing within the hospital which:
• Is separated from other hospital facilities.

• Is operated exclusively for providing professional care and treatment for critically
ill patients.
• Has special supplies and equipment necessary for such care and treatment
available on a standby basis for immediate use.
• Provides room and board; and
• Provides constant observation and care by registered nurses or other specially
trained hospital personnel.
Intensive Outpatient Program: An intensive outpatient program (IOP) is a kind of treatment

service and support program used primarily to treat eating disorders, depression, self-harm, and
chemical dependency that does not rely on detoxification. IOP operates on a small scale and does
not require the intensive residential or partial day services typically offered by the larger, more
comprehensive treatment facilities.

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Maintenance Care: Services and supplies provided primarily to maintain, support and/or
preserve a level of physical or mental function rather than to improve such function.
Maintenance Rehabilitation refers to therapy in which a patient actively participates, that is

provided after a patient has met the functional goals of active rehabilitation so that no continued
significant and measurable improvement is reasonably and medically anticipated, but where
additional therapy of a less intense nature and decreased frequency may reasonably be
prescribed to maintain, support, and or preserve the patient’s functional level. Maintenance
rehabilitation is not covered by the Plan.
Managed Care: Procedures designed to help control health care costs by avoiding unnecessary
services or services that are costlier than others that can achieve the same result.
Maximum Amount; Maximum Allowable Charge: The benefit payable for a specific coverage
item or benefit under the Plan. Maximum allowable charge(s) shall be calculated by the Plan
Administrator considering and after having analyzed:
• The reasonable and appropriate amount.

• The terms of the Plan:
• Plan negotiated and contractual rates with provider(s).
• The actual billed charges for the covered services; and
• Unusual circumstances or complications requiring additional time, skill, and
experience in connection with a service or supply, industry standards and
practices as they relate to similar scenarios, and the cause of injury or illness
necessitating the service(s) and/or charge(s).
• Medicare Allowable
The Plan will reimburse the actual charge(s) if they are less than the Plan’s Maximum Allowable
Charge amount(s). The Plan has the discretionary authority to decide if a charge is reasonable
and appropriate, as well as medically necessary. The Maximum Allowable Charge will not include
any identifiable billing mistakes including, but not limited to, up-coding, duplicate charges, and
charges for services not performed.
Medical management technique: A practice used to control the cost or use of health care
services, prescription drugs, or prescription drug use. The term includes, without limitation, the
use of step therapy, prior authorization and categorizing drugs and devices based on cost, type
or method of administration.
Medically Necessary: Health care 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:
1. Provided in accordance with generally accepted standards of medical practice;

2. Clinically appropriate with regard to type, frequency, extent, location and duration;

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3. Not primarily provided for the convenience of the patient, physician or other provider of
health care;
4. Required to improve a specific health condition of an insured or to preserve the existing
state of health of the insured; and
5. The most clinically appropriate level of health care that may be safely provided to the
insured.
A medical or dental service or supply will be appropriate if:
• It is a diagnostic procedure that is called for by the health status of the patient and is: as
likely to result in information that could affect the course of treatment as; and no more
likely to produce a negative outcome than any alternative service or supply, both with
respect to the illness or injury involved and the patient’s overall health condition.
• It is care or treatment that is likely to produce a significant positive outcome; and no more
likely to produce a negative outcome than any alternative service or supply, both with
respect to the illness or injury involved and the patient’s overall health condition.
• A medical or dental service or supply will be cost-efficient if it is no costlier than any
alternative appropriate service or supply when considered in relation to all health care
expenses incurred in connection with the service or supply. The fact that your physician or
dentist may provide, order, recommend or approve a service or supply does not mean that
the service or supply will be medically necessary for the medical or dental coverage
provided by the Plan. A hospitalization or confinement to a health care facility will not be
medically necessary if the patient’s illness or injury could safely and appropriately be
diagnosed or treated while not confined. A medical or dental service or supply that can
safely and appropriately be furnished in a physician’s or dentist’s office or other less costly
facility will not be medically necessary if it is furnished in a hospital or health care facility or
other costlier facility:
• The non-availability of a bed in another health care facility, or the non-availability of a Health
Care Practitioner to provide medical services will not result in a determination that
continued confinement in a hospital or other health care facility is medically necessary.
• A medical or dental service or supply will not be considered medically necessary if it does
not require the technical skills of a dental or health care practitioner or if it is furnished
mainly for the personal comfort or convenience of the patient, the patient’s family, any
person who cares for the patient, any dental or health care practitioner, hospital, or health
care facility.
Medically Necessary for External Review: Means health care 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, is clinically appropriate with regard to type, frequency, extent,
location and duration, is not primarily provided for the convenience of the patient, physician or
other provider of healthcare, is 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 participant.

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Medicare: The Health Insurance for the Aged and Disabled provisions in Title XVIII of the U.S.
Social Security Act as it is now amended and as it may be amended in the future.
Medicare Part A: Hospital insurance provided by the federal government that helps cover
inpatient care in hospitals, skilled nursing facility, hospice, and home health care.
Medicare Part B: Medical insurance provided by the federal government that helps pay for
medically necessary services like doctors' services, outpatient care, durable medical equipment,
home health services, and other medical services.
Medicare Part D: Prescription drug coverage subsidized by the federal government but is offered
only by private companies contracted with Medicare such as HMOs and PPOs.
Medi-Span: A national drug pricing information database for drug pricing analysis and
comparison.
Mental Disorder; Mental and Nervous Disorder: See the definition of Behavioral Health
Disorder.
Midwife, Nurse Midwife: A person legally licensed as a Midwife or certified as a Certified Nurse
Midwife in the area of managing the care of mothers and babies throughout the maternity cycle,
as well as providing general gynecological care, including history taking, performing physical
examinations, ordering laboratory tests and x-ray procedures, managing labor, delivery and the
post-delivery period, administer intravenous fluids and certain medications, provide emergency
measures while awaiting aid, perform newborn evaluation, sign birth certificates, and bill and be
paid in his or her own name, and who acts within the scope of his or her license. A Midwife may
not independently manage moderate or high-risk mothers, admit to a hospital, or prescribe all
types of medications. See also the definition of Nurse.
Morbid Obesity: Characterized by body mass index >40 kg/m(2) as defined by the National
Library of Medicine.
Naturopathy: A therapeutic system based on principles of treating diseases with natural forces
such as water, heat, diet, sunshine, stress reduction, physical manipulation, massage, or herbal
tea. Note: Naturopathy providers, treatment, services, or substances are not a payable benefit
under this Plan.
No Surprises Act means the federal No Surprises Act (Public Law 116-260, Division BB).
Nondurable Supplies: Goods or supplies that cannot withstand repeated use and/or that are
considered disposable and limited to either use by a single person or one-time use, including (but
not limited to) bandages, hypodermic syringes, diapers, soap, or cleansing solutions, etc. See also
the definitions of Corrective Appliances, Durable Medical Equipment, Orthotic Appliance (or
Device) and Prosthetic Appliance (or Device). Only those Nondurable Supplies identified in the
Schedule of Benefits are covered by this Plan. All others are not.

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Non-Network: See Out-of-Network.
Non-PPO emergency facility: An emergency department of a hospital, or an independent

freestanding emergency department (or a hospital, with respect to Emergency Services as
defined), that does not have a contractual relationship directly or indirectly with a group health
plan or group health insurance coverage offered by a health insurance issuer, with respect to the
furnishing of an item or service under the plan or coverage, respectively.
Non-PPO Provider or Non-Participating Provider: A health care provider who does not have a
contractual relationship directly or indirectly with the Plan with respect to the furnishing of an
item or service under the Plan.
Nurse: A person legally licensed as a Registered Nurse (RN), Certified Registered Nurse
Anesthetist (CRNA), Certified Nurse Midwife or licensed Midwife, Nurse Practitioner (NP),
Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), Psychiatric Mental Health
Nurse, or any equivalent designation, under the laws of the state or jurisdiction where the
services are rendered, who acts within the scope of his or her license.
Nurse Anesthetist: A person legally licensed as a Certified Registered Nurse Anesthetist (CRNA),
Registered Nurse Anesthetist (RNA) or Nurse Anesthetist (NA) and authorized to administer
Anesthesia in collaboration with a physician, and bill and be paid in his or her own name, or any
equivalent designation, under the laws of the state or jurisdiction where the services are
rendered, who acts within the scope of his or her license.
Nurse Practitioner: A person legally licensed as a Nurse Practitioner (NP), or Registered Nurse
Practitioner (RNP) who acts within the scope of his or her license and who in collaboration with
a physician, examines patients, establishes medical diagnoses; orders, performs and interprets
laboratory, radiographic and other diagnostic tests, identifies, develops, implements and
evaluates a plan of patient care, prescribes and dispenses medication, refers to and consults with
appropriate health care practitioners under the laws of the state or jurisdiction where the
services are rendered.
Occupational Therapist: A person legally licensed as a professional occupational therapist who

acts within the scope of their license and acts under the direction of a physician to assess the
presence of defects in an individual’s ability to perform self-care skills and activities of daily living
and who formulates and carries out a plan of action to restore or support the individual’s ability
to perform such skills to regain independence.
Office Visit: A direct personal contact between a physician or other health care practitioner and
a patient in the health care practitioner’s office for diagnosis or treatment associated with the
use of the appropriate office visit code in the Current Procedural Terminology (CPT) manual of
the American Medical Association and with documentation that meets the requirement of such
CPT coding. Neither a telephone discussion with a physician or other health care practitioner nor
a visit to a health care practitioner’s office solely for such services as blood drawing, leaving a
specimen, or receiving a routine injection is an office visit for the purposes of this Plan.

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Open Enrollment Period: The period during which participants in the Plan may select among the
alternate health benefit programs that are offered by the Plan or eligible individuals not currently
enrolled in the Plan may enroll for coverage.
Oral Surgery: The specialty of dentistry concerned with surgical procedures in and about the
mouth and jaw.
Orthognathic Services: Services dealing with the cause and treatment of malposition of the
bones of the jaw, such as Prognathism, Retrognathism or TMJ syndrome. See the definitions of
Prognathism, Retrognathism and TMJ.
Orthotic (Appliance or Device): A type of corrective appliance or device, either customized or

available “over-the-counter,” designed to support a weakened body part, including (but not
limited to) crutches, custom designed corsets, leg braces, extremity splints, and walkers. For the
purposes of the medical Plan, this definition does not include dental orthotics. See also the
definitions of Corrective Appliance, Durable Medical Equipment, Nondurable Supplies and
Prosthetic Appliance (or Device).
Other Prescription Drugs: Drugs that require a prescription under state law but not under federal
law.
Out-of-Network Rate: With respect to items and services furnished by a Non-PPO

provider, Non-Network emergency facility or Non-PPO provider of ambulance services,
means one of the following:
• the amount the parties negotiate;
• the amount approved under the independent dispute resolution (IDR) process; or
• if the state has an All-Payer Model Agreement, the amount that the state approves
under that system
Out-of-Network Services (Non-Network): Services provided by a health care provider that is not
a member of the Plan’s Preferred Provider Organization (PPO), as distinguished from In-Network
services that are provided by a health care provider that is a member of the PPO. Greater expense
could be incurred by the participant when using Out-of-Network providers.
Out-of-Pocket Maximum (OOPM): The maximum amount of Coinsurance each covered person
or family is responsible for paying during a Plan Year before the Coinsurance required by the Plan
ceases to apply. When the Out-of-Pocket Maximum is reached, the Plan will pay 100% of eligible
covered expenses for the remainder of the Plan Year. See the section on Out-of-Pocket Maximum
in the Medical Expense Coverage section for details about what expenses do not count toward
the Out-of-Pocket Maximum.
Outpatient Hospital Laboratory and Outpatient Hospital-Based Laboratory Draw Station:

Outpatient hospital-based laboratory facilities include lab services performed in a hospital
outpatient setting. Outpatient hospital-based laboratory draw stations are hospital affiliated

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whereby the draw station collects specimens and sends them to the central hospital lab for
processing.
Outpatient Services: Services provided either outside of a hospital or health care facility setting
or at a hospital or health care facility when room and board charges are not incurred.
Partial Hospitalization Service: Also known as PHP, is a type of program used to treat mental
illness and substance abuse in which the patient continues to reside at home but commutes to a
treatment center up to seven days a week. This service model focuses on the overall treatment
of the individual and is intended to avert or reduce in-patient hospitalization. Services are
typically provided in either a hospital setting or by a free-standing community mental health
center. Treatment during a typical day may include group therapy, psych-educational groups, skill
building, individual therapy, and psychopharmacological assessments, and check-ins. Programs
are available for the treatment of alcoholism and substance abuse, Alzheimer's disease, anorexia
and bulimia, depression, bipolar disorder, anxiety disorders, schizophrenia, and other mental
illnesses.
Participant: The employee or retiree or their enrolled spouse or domestic partner or dependent
child(ren) or a surviving spouse or dependent of a retiree.
Participating Provider: A health care provider who participates in the Plan’s Preferred Provider
Organization (PPO).
Passive Rehabilitation: Refers to therapy in which a patient does not actively participate because
the patient does not have the ability to learn and/or remember (that is, has a cognitive deficit),
or is comatose or otherwise physically or mentally incapable of active participation. Passive
rehabilitation may be covered by the Plan, but only during a course of hospitalization for acute
care. Techniques for passive rehabilitation are commonly taught to the family/caregivers to
employ on an outpatient basis with the patient when and until the patient can achieve active
rehabilitation. Continued hospitalization for the sole purpose of providing passive rehabilitation
will not be medically necessary for the purposes of this Plan.
Pharmacy: A licensed establishment where covered prescription drugs are filled and dispensed
by a pharmacist licensed under the laws of the state where he or she practices.
Pharmacist: A person legally licensed under the laws of the state or jurisdiction where the
services are rendered, to prepare, compound and dispense drugs and medicines, and who acts
within the scope of his or her license.
Physical Therapy: Rehabilitation directed at restoring function following disease, injury, surgery,
or loss of body part using therapeutic properties such as active and passive exercise, cold, heat,
electricity, traction, diathermy, and/or ultrasound to improve circulation, strengthen muscles,
return motion, and/or train/retrain an individual to perform Activities of daily living such as
walking and getting in and out of bed.

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Physician: A person legally licensed as a Medical Doctor (MD) or Doctor of Osteopathy (DO) and
authorized to practice medicine, to perform surgery, and to administer drugs, under the laws of
the state or jurisdiction where the services are rendered who acts within the scope of his or her
license.
Physician Assistant (PA): A person legally licensed as a physician assistant, who acts within the
scope of his or her license and acts under the supervision of a physician to examine patients,
establish medical diagnoses; order, perform and interpret laboratory, radiographic and other
diagnostic tests; identify, develop, implement and evaluate a plan of patient care; prescribe and
dispense medication within the limits of his or her license; refer to and consult with the
supervising physician; under the laws of the state or jurisdiction where the services are rendered.
Plan, The Plan, This Plan: In most cases, the programs, benefits, and provisions described in this
document as provided by the Public Employees’ Benefits Program (PEBP).
Plan Administrator: The person or legal entity designated by the Plan as the party who has the
fiduciary responsibility for the overall administration of the Plan.
Plan Year: Typically, the 12-month period from July 1 through June 30. PEBP has the authority to
revise the Plan Year if necessary. PEBP has the authority to revise the benefits and rates, if
necessary, each Plan Year. For medical, dental, vision and pharmacy benefits, all Deductibles,
Out-of-Pocket Maximums and Plan Year maximum benefits are determined based on the Plan
Year.
Plan Year Deductible: The amount you must pay each Plan Year before the Plan pays benefits.
Plan Year Maximum Benefits: The maximum benefits payable each Plan Year for certain medical
expenses incurred by any covered Plan participant (or covered family member of the Plan
participant).
Podiatrist: A person legally licensed as a Doctor of Podiatric Medicine (DPM) who acts within the
scope of his or her license and who is authorized to provide care and treatment of the human
foot (and in some states, the ankle and leg up to the knee) under the laws of the state or
jurisdiction where the services are rendered.
Pre-Admission Testing: Laboratory tests and x-rays and other medically necessary tests
performed on an outpatient basis, 7 days prior to a scheduled hospital admission or outpatient
surgery. The testing must be related to the sickness or injury.
Precertification (preauthorization, prior authorization): Is a process used by the UM company

and Pharmacy Benefit Manager to determine if a prescribed procedure, including, but not limited
to inpatient admission, concurrent review, DME, outpatient services, or medication are medically
necessary before the services and supplies are received. A precertification is not a guarantee of
payment.

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Preferred Provider Organization (PPO): A group or network of health care providers (e.g.,
hospitals, physicians, laboratories) under contract with the Plan to provide health care services
and supplies at agreed-upon discounted or reduced rates.
Prescribed for a Medically Necessary Indication: The term medically necessary indication means
any use of a covered outpatient drug which is approved under the Federal Food, Drug and
Cosmetic Act, or the use of which is supported by one or more citations included or approved for
inclusion in any of the following compendia: American Hospital Formulary Service Drug
Information, United States Pharmacopeia-Drug Information, the DRUGDEX Information System
or American Medical Association Drug Evaluations.
Prescription Drugs: For the purposes of this Plan, prescription drugs include:
• Federal Legend Drugs: Any medicinal substance that the Federal Food, Drug, and
Cosmetic Act requires to be labeled, “Caution - Federal law prohibits dispensing
without prescription”.
• Other prescription drugs: drugs that require a prescription under state law but not
under federal law; or
• Compound drugs: Any drug that has more than one ingredient and at least one of
them is a Federal Legend Drug or a drug that requires a prescription under state
law.
Prescription Prior Authorization (PA): Also known as “coverage review,” this is a process the
Plan’s Pharmacy Benefit Manager might use to decide if your prescribed medicine will be
covered. The Plan uses this to help control costs and to ensure the medicine being prescribed is
an effective treatment for the condition.
Primary Care Doctor or Primary Care Physician (PCP): A physician or group of physicians who:
1. Provides initial and primary health care services to an insured;

2. Maintains the continuity of care for the insured; and
3. May refer the insured to a specialized provider of health care.
This may include a physician in family practice, internal medicine, pediatrics, obstetrics and
gynecology.
Prognathism: The malposition of the bones of the jaw resulting in projection of the lower jaw
beyond the upper part of the face.
Program: Means the Public Employees’ Benefits Program.
Prophylactic Surgery: A surgical procedure performed for
• avoiding the possibility or risk of an illness, disease, physical or mental disorder or

condition based on genetic information or genetic testing, or

161
• treating the consequences of chromosomal abnormalities or genetically

transmitted characteristics, when there is an absence of objective medical
evidence of the presence of disease or physical or mental disorder, even at its
earliest stages.
An example of prophylactic surgery is a mastectomy performed on a woman who has been

diagnosed as having a genetic predisposition to breast cancer or has a history of breast cancer
among her family members when, at the time the surgery is to be performed, there is no
objective medical evidence of the presence of the disease, even if there is medical evidence of a
chromosomal abnormality or genetically transmitted characteristic indicating a significant risk of
breast cancer coupled with a history of breast cancer among family members of the woman.
Prophylaxis: The removal of tartar and stains from the teeth. The cleaning and scaling of the
teeth are performed by a dentist or dental hygienist.
Prospective Payment System (PPS): This Plan follows CMS’s Prospective Payment System (PPS)
where the Plan’s payment is based on a predetermined, fixed amount payable to a facility for
inpatient or outpatient hospital services. The Plan will not allow separate reimbursement for
specific HCPCS supplies, DME, orthotics, prosthetics, biological, and drugs billed on a HCFA claim
form by any physician or other qualified healthcare professional in the following facility POS
(place of service) 19, 21, 22, 23, and 24, see the following POS descriptions:
• POS 19 Off Campus – Outpatient Hospital: A portion of an off-campus hospital

provider-based department which provides diagnostic, therapeutic (both surgical
and non-surgical), and rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
• POS 21 Inpatient Hospital: A facility, other than psychiatric, which primarily
provides diagnostic, therapeutic (both surgical and nonsurgical), rehabilitation
services by, or under, the supervision of physicians to patients admitted for a
variety of medical conditions.
• POS 22 On Campus – Outpatient Hospital: A portion of a hospital’s main campus
which provides diagnostic, therapeutic (both surgical and non-surgical), and
rehabilitation services by, or under, the supervision physicians to patients
admitted for a variety of medical conditions.
• POS 23 Emergency Room – Hospital: A portion of a hospital where emergency
diagnosis and treatment of illness and injury is provided.
• POS 24 Ambulatory Surgery Center: A freestanding facility, other than a
physician’s office, where surgical and diagnostic services are provided on an
ambulatory basis.
Prosthetic Appliance (or Device): A type of corrective appliance or device designed to replace all
or part of a missing body part, including (but not limited to) artificial limbs, heart pacemakers, or
corrective lenses needed after cataract surgery. See also the definitions of Corrective Appliances,
Durable Medical Equipment, Nondurable Supplies and Orthotic Appliance (or Device).

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Provider: A health care practitioner as defined above, or a hospital, ambulatory surgical facility,
behavioral health treatment facility, birthing center, home health care agency, hospice, skilled
nursing facility, or sub-acute care facility (as those terms are defined in this Key Terms and
Definitions Section).
Qualified Individual: A covered individual who is eligible, according to clinical trial protocol, to
participate in an approved clinical trial and either: (i) the referring health care professional is an
in-network provider and has concluded that the covered individual’s participation in the clinical
trial would be appropriate; or (ii) the covered individual provided medical and scientific
information establishing that the individual’s participation in the clinical trial would be
appropriate.
Qualified Medical Child Support Orders (QMCSO): QMCSOs are state court orders requiring a
parent to provide medical support to a child often because of legal separation or divorce and
also include a National Medical Support Notice. A QMCSO may require the Plan to make
coverage available to your child even though, for income tax or Plan purposes, the child is not
your dependent. To qualify, a medical support order must be a judgment, decree, or order
(including approval of a settlement agreement) issued by a court of competent jurisdiction or
by an administrative agency, which:
• Specifies your last known name and address and the child’s last known name and
address.
• Describes the type of coverage to be provided, or how the type of coverage will
be determined.
• States the period to which it applies; and
• Specifies each plan to which it applies.
The QMCSO cannot require the Plan to cover any type or form of benefit that they do not
currently cover. The Plan must pay benefits directly to the child, or to the child’s custodial parent
or legal guardian, consistent with the terms of the order and Plan provisions. You and the affected
child will be notified if an order is received.
Qualifying Payment Amount (QPA) means the amount calculated using the methodology
described in 29 CFR 716-6(c).
Quantity Limit: The maximum amount of a medication the Plan covers during a period of time.
These limits are set for safety reasons and to help reduce costs.
Reasonable and/or Reasonableness: Means charges for services or supplies which are necessary
for the care and treatment of an illness or injury. The determination that charges are reasonable
will be made by the Plan Administrator taking into consideration the following:
• The facts and circumstances giving rise to the need for the service or supply.
• Industry standards and practices as they are related to similar scenarios; and

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• The cause of the injury or illness necessitating the service or charge.
The Plan Administrator’s determination will consider but will not be limited to evidence-based
guidelines, and the findings and assessments of the following entities:
• The National Medical Associations, Societies, and Organizations;
• The Centers for Medicare and Medicaid Services (CMS);
• Centers for Disease Control and Prevention; and
• The Food and Drug Administration.
To be reasonable, charges must follow generally accepted billing practices for unbundling or
multiple procedures. The Plan Administrator retains discretionary authority to determine
whether a charge is reasonable. The Plan reserves for itself and parties acting on its behalf the
right to review charges processed and/or paid by the Plan, to identify charges that are not
reasonable and therefore not eligible for payment by the Plan.
Reconstructive Surgery: A medically necessary surgical procedure performed on an abnormal or

absent structure of the body to correct damage caused by a congenital birth defect, an accidental
injury, infection, disease, or tumor, or for breast reconstruction following a total or partial
mastectomy.
Reference Based Pricing/Reference Price: A methodology that determines the cost for a covered
service based on a market or industry benchmark or reference price. The Plan Administrator may
utilize this method in determining the Maximum Allowable Charge.
Rehabilitation Therapy: Physical, occupational, or speech therapy that is prescribed by a

physician when the bodily function has been restricted or diminished as a result of illness, injury
or surgery, with the goal of improving or restoring bodily function by a significant and measurable
degree to as close as reasonably and medically possible to the condition that existed before the
injury, illness or surgery, or medically necessary treatment of a behavioral health condition, and
that is performed by a licensed therapist acting within the scope of his or her license. See the
Schedule of Benefits and the Exclusions section of this document to determine the extent to
which rehabilitation therapies are covered. See also the definition of Physical Therapy,
Occupational Therapy, Speech Therapy and Cardiac Rehabilitation.
Reimbursable Payments: Payments made by this Plan for benefits, including any payment for a
covered pre-existing condition that are or become the responsibility of another party under the
subrogation provisions as described in this MPD.
Rescission: A cancellation or discontinuance of coverage under the Plan that has a retroactive
effect. Rescission does not include a cancellation or discontinuance of coverage under the Plan if
• The cancellation or discontinuance of coverage has only a prospective effect; or

164
• The cancellation or discontinuance of coverage is effective retroactively to the

extent it is attributable to a failure to timely pay required premiums or
contributions towards the cost of coverage
Retiree: Unless specifically indicated otherwise, when used in this document, Retiree refers to a
person formerly employed by an agency or entity that may or may not participate in the PEBP
program and who is eligible to enroll for coverage under this Plan.
Retrognathism: The malposition of the bones of the jaw resulting in the retrogression of the
lower jaw from the upper part of the face.
Retrospective Review: Review of health care services after they have been provided to
determine if those services were medically necessary and/or if the charges for them are Usual
and Customary Charges and do not exceed the Plan’s Maximum Allowable Charge or negotiated
fee schedule.
Second Opinion: A consultation and/or examination, preferably by a board-certified physician

not affiliated with the primary attending physician, to evaluate the medical necessity and
advisability of undergoing surgery or receiving a medical service.
Serious and Complex Condition: With respect to a participant, beneficiary, or enrollee under
the Plan one of the following:
• in the case of an acute illness, a condition that is serious enough to require specialized
medical treatment to avoid the reasonable possibility of death or permanent harm;
in the case of a chronic illness or condition, a condition that is—
• is life-threatening, degenerative, potentially disabling, or congenital; and
• requires specialized medical care over a prolonged period of time.
Service Area: The geographic area serviced by the In-Network providers who have agreements
with the Plan’s network.
Sickle Cell Disease: An inherited disease caused by a mutation in a gene for hemoglobin in which
red blood cells have an abnormal crescent shape that causes them to block small blood cells and
die sooner than normal red blood cells and may include sickle cell disease, one or more variants
or a combination thereof, as applicable.
Significantly Inferior Coverage: The PEBP Board has defined Significantly Inferior Coverage as
either:
• A mini-med or other limited benefit plan; or

• Catastrophic coverage plans with a Deductible equal to or greater than $5,000 for single
coverage with no employer contributions to a Health Savings Account or Health
Reimbursement Arrangement.

165
Skilled Nursing Care: Services performed by a licensed nurse (RN, LVN or LPN) if the services are
ordered by and provided under the direction of a physician; and are intermittent and part-time,
generally not exceeding 16 hours a day, and are usually provided on less-than-daily basis; and
require the skills of a nurse because the services are so inherently complex that they can be safely
and effectively performed only by or under the supervision of a nurse. Examples of skilled nursing
care services include but are not limited to the initiation of intravenous therapy and the initial
management of medical gases such as oxygen.
Skilled Nursing Facility or Extended Care/Skilled Nursing Facility: A public or private facility,
licensed and operated according to law, that primarily provides skilled nursing and related
services to people who require medical or nursing care and that rehabilitates injured, sick people
or people with disabilities, and that meets all the following requirements:
• Is licensed pursuant to state and local laws.
• Is operated primarily for providing skilled nursing care and treatment for
individuals convalescing from injury or illness.
• Is approved by and is a participating facility with Medicare.
• Has organized facilities for medical treatment.
• Provides 24-hour-a-day nursing service under the full-time supervision of a
physician or registered nurse.
• Maintains daily clinical records on each patient.
• Has available the services of a physician under an established agreement.
• Provides appropriate methods for dispensing and administering drugs and
medicines.
• Has transfer arrangements with one or more hospitals; a utilization review plan in
effect; and operational policies developed with the advice of and reviewed by a
professional group including at least one physician; and
• Is not an institution which is mainly a rest home; a home for the aged; a place for
drug addicts; a place for alcoholics; or a place for the treatment of mental illness.
A skilled nursing facility that is part of a hospital, as defined in this document, will be considered
a skilled nursing facility for the purposes of this Plan.
Special Food Product: A food product that is specially formulated to have less than one gram of
protein per serving and is intended to be consumed under the direction of a physician for the
dietary treatment of an inherited metabolic disease. The term does not include a food that is
naturally low in protein.
Specialist Physician: A doctor who has completed advanced education and training in a
specific field of medicine and who treats only certain parts of the body, certain health
problems, or certain age groups. For example, some doctors treat only heart problems.
Specialty Care Unit: A section, ward, or wing within a hospital that offers specialized care for the
patient’s needs. Such a unit usually provides constant observation, special supplies, equipment,

166
and care provided by Registered nurses or other highly trained personnel. Examples include
Intensive Care Units (ICU) and Cardiac Care Units (CCU).
Speech Therapy: Rehabilitation directed at treating defects and disorders of spoken and written
communication,
Spinal Manipulation / Chiropractic Care: The detection and correction, by manual or mechanical
means, of the interference with nerve transmissions and expressions resulting from distortion,
misalignment, or dislocation of the spinal (vertebrae) column. Spinal manipulation is commonly
performed by chiropractors, but it can be performed by physicians.
Spouse: The employee’s lawful spouse. The Plan will require proof of the legal marital
relationship. A legally separated spouse or divorced former spouse or domestic partner of an
employee or retiree is not an eligible spouse under this Plan.
Standard Plan Benefits (Standard Benefits): Standard Plan Benefits or Standard Benefits under
this Plan means the participant is covered under the Plan’s Standard Benefits and is not eligible
for enhanced benefits due to non-participating and or engaging in the Diabetes Care
Management or Obesity Care and Overweight Management Programs.
State: When capitalized in this document, the term State means the State of Nevada.
Step Therapy: see also “Medical Management technique.” A process designed to help control
high medicine costs. If the Plan applies step therapy to your medication, it will require that you
try a lower-cost medication that is proven effective to treat your condition, before it will cover a
higher-cost medicine. If the lower cost medicine does not treat your condition effectively, the
Plan’s coverage will “step” you to a higher-cost medicine to find a medicine that treats your
condition effectively at the lowest possible cost.
The Plan also complies with step therapy for treatment of cancer or cancer symptom that is part
of step therapy protocol per NRS 695G.1675.
Sub-acute Care Facility: A public or private facility, either free-standing, hospital-based or based
in a skilled nursing facility, licensed and operated according to law and authorized to provide sub-
acute care, that primarily provides, immediately after or instead of acute care, comprehensive
inpatient care for an individual who has had an acute illness, injury, or exacerbation of a disease
process, with the goal of discharging the patient after a limited term of confinement, to the
patient’s home or to a suitable skilled nursing facility, and that meets all of the following
requirements:
• It is accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) as a Sub-Acute Care Facility or is recognized by Medicare
as a Sub-Acute Care Facility; and
• It maintains on its premises all facilities necessary for medical care and treatment;
and

167
• It provides services under the supervision of physicians; and

• It provides nursing services by or under the supervision of a licensed Registered
Nurse; and
• It is not (other than incidentally) a place for rest, domiciliary care, or care of people
who are aged, alcoholic, blind, deaf, drug addicts, mentally deficient, or suffering
from tuberculosis; and
• It is not a hotel or motel.
Substance Abuse: A psychological and/or physiological dependence or addiction to alcohol or

drugs or medications, regardless of any underlying physical or organic cause, and/or other drug
dependency as defined by the current edition of the ICD manual or identified in the current
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See the definitions
of behavioral health disorders and chemical dependency.
Surgery/Surgeries: Any operative or diagnostic procedure performed in the treatment of an

injury or illness by instrument or cutting procedure through an incision or any natural body
opening. When more than one surgical procedure is performed through the same incision or
operative field or at the same operative session, the claims administrator will determine which
multiple surgical procedures will be considered as primary, secondary, bilateral, add-on, or
separate (incidental) procedures for determining benefits under this Plan.
Multiple Surgical Procedure Allowances:

• Primary procedure, bilateral primary procedure, or add-on to primary procedure:
usual and customary, subject to the Plan’s Maximum Allowable Charge or
negotiated fee.
• Secondary procedure in same operative area: limited to 50% of usual and
customary charge, subject to the Plan’s Maximum Allowable Charge or negotiated
fee.
• Bilateral secondary procedure in same operative area: limited to 50% of usual and
customary charge, subject to the Plan’s Maximum Allowable Charge or negotiated
fee.
• Add-on to secondary procedure in same operative area: limited to 100% of usual
and customary charge, subject to the Plan’s Maximum Allowable Charge or
negotiated fee.
• Separate (incidental) procedure in same operative area as any of the above: not
covered.
• Separate operative area: limited to 50% of usual and customary charge, subject to
the Plan’s Maximum Allowable Charge or negotiated fee.
Telehealth: Telehealth means the delivery of services from a provider of health care to a patient
at a different location using information and audio-visual communication technology, not
including facsimile, or electronic mail.

168
Telehealth is a general term used to describe clinical services provided to patients through
electronic communications not through a vendor. This can be patient-to-physician. Examples
include patient consultation with a specialist that is out of the patient’s geographical area or
patient has a virtual visit with their primary care physician. Telehealth is the use of digital
information and communication technologies, such as computers and mobile devices, to access
health care services remotely and manage your health.
Telemedicine: Telemedicine (vendor/virtual visit) is the practice of medicine using technology to

deliver care at a distance via electronic communications through a vendor.
Temporomandibular Joint (TMJ), Temporomandibular Joint (TMJ) Dysfunction or Syndrome:

The Temporomandibular (or craniomandibular) Joint (TMJ) connects the bone of the temple or
skull (temporal bone) with the lower jawbone (the mandible). TMJ Dysfunction or Syndrome
refers to a variety of symptoms where the cause is not clearly established, including (but not
limited to) masticatory muscle disorders producing severe aching pain in and about the TMJ
(sometimes made worse by chewing or talking); myofascial pain, headaches, earaches, limitation
of the joint, clicking sounds during chewing; tinnitus (ringing, roaring, or hissing in one or both
ears) and/or hearing impairment. These symptoms may be associated with conditions such as
malocclusion (failure of the biting surfaces of the teeth to meet properly), ill-fitting dentures, or
internal derangement of the TMJ.
Termination: Includes, with respect to the Continuation of Care benefit, the expiration or
nonrenewal of the contract, but does not include a termination of the contract for failure to meet
applicable quality standards or for fraud.
Therapist: A person trained in and skilled in giving therapy in a specific field of health care such
as occupational, physical, radiation, respiratory and speech therapy. See the Occupational,
Physical and Speech Therapy section.
Tortfeasor: Means an individual or entity who commits a wrongful act, either intentionally or
through negligence, which injures another or for which the law provides a legal right through a
civil case for the injured person to seek relief.
Transplant, Transplantation: The transfer of organs (such as the heart, kidney, liver) or living
tissue/cells (such as bone marrow, stem cells or skin) from a donor to a recipient with the intent
to maintain the functional integrity of the transplanted organ or tissue in the recipient. (See the
Schedule of Benefits and Exclusions section for additional information regarding transplants. See
also the Utilization Management section of this document for information about precertification
requirements for transplantation services).
Xerographic: Refers to transplants of organs, tissues, or cells from one species to another (for
example, the transplant of an organ from a baboon to a human). Xerographic transplants are not
covered by this Plan, except heart valves.

169
Urgent Care: Health care services that are required by the onset of a medical condition that
manifests itself by symptoms of sufficient severity that prompt medical attention is appropriate,
even though health and life are not in jeopardy. Examples of medical conditions that may be
appropriate for urgent care include (but are not limited to) fever, sprains, bone, or joint injuries,
continuing diarrhea, vomiting, or bladder infections.
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 participant’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 participant’s medical conditions, would
subject the participant 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 precertification of an
urgent care service was denied, the participant could request an expedited appeal for the urgent
care claim.
Urgent Care Facility: A public or private hospital-based or free-standing facility, which includes
x-ray and laboratory equipment and a life support system, licensed or legally operating as an
urgent care facility, primarily providing minor emergency and episodic medical care with one or
more physicians, nurses, and x-ray technicians in attendance when the facility is open.
Usual and Customary: Covered expenses which are identified by PEBP, taking into consideration
the fee(s) which the provider most frequently charges (or accepts for) most patients for the
service or supply, the cost to the provider for providing the services, the prevailing range of fees
charged in the same “area” by providers of similar training and experience for the service or
supply, and the Medicare reimbursement rates. The term(s) “same geographic locale” and/or
“area” shall be defined as a metropolitan area, country, or such greater area as is necessary to
obtain a representative cross- section of providers, persons or organizations rendering such
treatment, services, or supplies for which a specific charge is made.
To be Usual and Customary, fee(s) must follow generally accepted billing practices for unbundling
or multiple procedures.
The term “Usual” refers to the amount of a charge made or accepted for medical services, care,
or supplies, to the extent that the charge does not exceed the common level of charges made by
other medical professionals with similar credentials, or health care facilities, pharmacies, or
equipment suppliers of similar standing, which are in the same geographic locale in which the
charge is incurred.
The term “Customary” refers to the form and substance of a service, supply, or treatment
provided in accordance with generally accepted standards of medical practice to one individual,
which is appropriate for the care or treatment of the same sex, comparable age and who receive
such services or supplies within the same geographic locale.

170
The term “Usual and Customary” does not necessarily mean the actual charge made nor the
specific service or supply furnished to a participant by a provider of services or supplies, such as
a physician, therapist, nurse, hospital, or pharmacist. The Plan Administrator will determine what
the Usual and Customary charge is, subject to the Plan’s Maximum Allowable Charge or
negotiated fee schedule for any procedure, service, or supply, and whether a specific procedure,
service or supply is usual and customary. Usual and customary charges may, at the Plan
Administrator’s discretion, alternatively be determined and established by the Plan using
normative data such as, but not limited to, Medicare cost to charge ratios, Average Wholesale
Price (AWP) for prescriptions and/or manufacturer’s retail pricing (MRP) for supplies and devices.
Utilization Management (UM): A managed care process to determine the medical necessity,
appropriateness, location, and cost-effectiveness of health care services. This review can occur
before, during or after the services are rendered and may include (but is not limited to):
precertification; concurrent and/or continued stay review; discharge planning; retrospective
review; case management; hospital or other health care provider bill audits; and health care
provider fee negotiation. Utilization management services (sometimes referred to as UM
services, UM, utilization review services, UR services, utilization management, concurrent
review, or retro review services) are provided by licensed health care professionals employed by
the utilization management company operating under a contract with the Plan.
Utilization Management Company (UM company): The independent utilization management

organization, staffed with licensed health care professionals, who utilize nationally recognized
health care screening criteria along with the medical judgment of their licensed health care
professional, operating under a contract with the Plan to administer the Plan’s utilization
management services.
Visit: See the definition of office visit.
Well Baby Care; Well Child Care: Health care services provided to a healthy newborn or child
that are determined by the Plan to be medically necessary, even though they are not provided
because of illness, injury, or congenital defect. The Plan’s coverage of well-baby care is described
under Preventive Care/Wellness Services and in the Schedule of Benefits.
You, Your: When used in this document, these words refer to the employee or retiree who is
covered by the Plan. They do not refer to any dependent of the employee or retiree.

171

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CONSUMER DRIVEN HEALTH PLAN

MASTER PLAN DOCUMENT

(EFFECTIVE JULY 1, 2024 – JUNE 30, 2025)

Public Employees’ Benefits Program

Amendment Log .................................................................................................................................................. vii

Welcome PEBP Participant .................................................................................................................................... 8

Participant Rights ................................................................................................................................................ 12

Summary of the CDHP Components..................................................................................................................... 13

Description of In-Network and Out-of-Network .................................................................................................. 18

Eligible Medical Expenses .................................................................................................................................... 22

Non-Eligible Medical Expenses ............................................................................................................................ 23

Health Savings Accounts (HSA) ............................................................................................................................ 26

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Active Employees Only............................................................................................................................................. 26

Health Reimbursement Arrangement (HRA) ........................................................................................................ 29

HRA Contributions for Eligible Active Employees and Retirees ............................................................................ 30

One-Time HSA or HRA Funding for Active State Employees ................................................................................. 32

HSA/HRA Contributions for Eligible State Active Employees ................................................................................ 32

Utilization Management ...................................................................................................................................... 33

Schedule of Benefits ............................................................................................................................................ 45

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Acupuncture and Acupressure ................................................................................................................................. 46

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Oral Surgery, Dental Services, and Temporomandibular Joint Disorder.................................................................. 74

Schedule of Prescription Drug Benefits ................................................................................................................ 89

Benefit Limitations and Exclusions ....................................................................................................................... 97

Claims Administration ....................................................................................................................................... 111

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Appeals .............................................................................................................................................................. 113

Coordination of Benefits .................................................................................................................................... 124

Subrogation and Third-Party Recovery .............................................................................................................. 130

Participant Contact Guide .................................................................................................................................. 131

Key Terms and Definitions ................................................................................................................................. 134

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

1. May 10, 2024 - Amended telemedicine/Doctor on Demand section, pg 83, to

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Welcome PEBP Participant

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Suggestions for Using this Document

Accessing Other Benefit Information:

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

• Exclusive Provider Organization Plan Master Plan Document

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Public Employees' Benefits Program CDHP Plan Year 2025

Summary of the CDHP Components

The Plan includes:

Family Family: $3,200

Public Employees' Benefits Program CDHP Plan Year 2025

In-Network Individual Deductible

Out-of-Network Individual Deductible

In-Network Family Deductible

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Out-of-Network Family Deductible

• An Individual (covered as self-only) is $4,000

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Out-of-Network Out-of-Pocket Maximum

• Individual (covered as self-only) is $10,600.

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025

Public Employees’ Benefits Program CDHP-PPO Plan Year 2025