HEALTH SUITE SELECT
SMALL GROUP PLANS
Flexible, small group plans for Nevada small businesses
Groups effective January 1, 2017
Small group employers may offer up to three plans from the available Health Suite Select series. You and
your clients can tailor options by selecting a combination of any three plans or as few as one providing that
membership is attached to each plan.
Employees can then select the plan that works best for them and their lifestyle. The idea is to offer employers
and their employees maximum choice and flexibility at an affordable cost.
Empowering employees to make the decision about their healthcare provides them with the opportunity to
be an active participant in selecting the plan that is right for them.
www.prominencehealthplan.com
Small Group health plans for coverage effective January 1, 2017
Please contact your Prominence Health Plan account executive or account manager with questions
or for more information about PPO product options.
HMO Product Line
HMO CORE PLANS
PCP/
Specialist
Deductible
(3x family)
Coinsurance
OOPM(1)
(2x Family)
Inpatient
Copay
Emergency
Room
Urgent Care
Rx(2)
HMO
Core 1
$20/$40
$0
10%
outpatient
$3,000
$650 per
admit
$250 copay
$50 copay
$10/30/50
HMO
Core 2
$25/$50
$0
10%
outpatient
$5,500
$500 per day/
3 days max
$250 copay
$50 copay
$10/30/50
HMO
Core 3
$40/$80
$0
15%
outpatient
$6,350
$2,000 per
admit
$350 copay
$50 copay
$25/75/125
Plan
HMO DEDUCTIBLE PLANS
Inpatient Copay
Emergency
Room
Urgent
Care
Rx(2)
$3,500
CYD then $750
per admit
$250 copay
$50
copay
$25/70/95
15%
outpatient
$6,850
CYD then $2,000
per admit
CYD/
$400 copay
$50
copay
$25/70/95
$1,500
10%
outpatient
$4,500
CYD then $1,500
per admit
$250 copay
$50
copay
$15/40/60
$40/$75
$2,250
20%
outpatient
$7,150
CYD then $2,000
per admit
CYD/
$400 copay
$50
copay
$30/60/95
HMO DED 8
3 visits at $60 then
CYD/ Coins;
spec CYD then $90
$5,500
(2x family)
50%
outpatient
$6,850
CYD then $1,100
per day/ 5 days
max
CYD/
$600 copay
CYD then
$100
copay
$30/85/CYD
then 20%
Coins
HMO DED 9
VALUE
2 visits at $65 then
CYD/Coins;
$125 spec copay
$6,300
(2x family)
40%
outpatient
$7,150
CYD then
40% Coins
CYD/
$750 copay
$100
copay
$35/100/CYD
then 50%
Coins
Deductible
Plan
PCP/Specialist
HMO DED 1
$30/$50
$1,000
10%
outpatient
HMO DED 2
$45/$85
$2,250
HMO DED 4
$40/$60
HMO DED 5
(3x family)
Coinsurance
OOPM(1)
(2x family)
HMO BEYOND PLANS
PCP/
Specialist
Deductible
HMO
Beyond 1A
$15/$40
$500
20%
HMO
Beyond 2A
$20/$40
$850
HMO
Beyond 3A
$25/$50
HMO
Beyond 4A
HMO
Beyond 5A
Plan
Inpatient
Copay
Emergency
Room
Urgent Care
Rx(2)
$2,500
CYD then 20%
coins
$200 copay
$50 copay
$5/15/30
20%
$5,000
CYD then 20%
coins
$250 copay
$50 copay
$15/40/60
$1,000
30%
$5,000
CYD then 30%
coins
$250 copay
$50 copay
$10/30/50
$20/$40
$2,000
20%
$6,350
CYD then 20%
coins
$200 copay
$50 copay
$10/30/50
$20/$40
$2,000
0%
$4,500
CYD then 0%
coins
$250 copay
$50 copay
$15/40/60
(3x family)
Coinsurance
OOPM(1)
(2x family)
HMO small group plans include pediatric dental with coverage for preventive at no charge. Basic/major and orthodontics
subject to the medical plan deductible and covered in-network at 20/50%/50% respectively.
(1) Deductibles, coinsurance and copayments accrue toward the out-of-pocket maximum (OOPM). The following cannot be used to satisfy the OOPM:
• Penalty for failure to obtain prior authorization; and use of emergency department for non-emergency needs
(2) Specialty pharmacy drugs are paid at a percentage up to the OOPM.
HMO HD PLANS
Plan
PCP/Specialist
Deductible
(3x family)
Coinsurance
(2x family)
OOPM(1)
Inpatient
Copay
Emergency
Room
Urgent Care
Rx(2)
HMO HD
Core 1
CYD/Coins
$2,800(3)
0%
$5,000
CYD/Coins
CYD then
0% coins
CYD/Coins
CYD then
$25/50/75
HMO HD
Core 3
CYD/Coins
$3,000(4)
0%
$5,000
CYD/Coins
CYD then
0% coins
CYD/Coins
CYD then
$10/40/60
HMO HD
Core 4
CYD/Coins
$3,500(4)
0%
$5,500
CYD/Coins
CYD then
0% coins
CYD/Coins
CYD then
$10/30/50
HMO HD
Core 6
CYD/Coins
$2,000(3)
20%
$6,450
CYD/Coins
CYD then
20% coins
CYD/Coins
CYD then
$10/40/60
HMO HD
Core 7
CYD/Coins
$3,000(4)
10%
$6,000
CYD/Coins
CYD then
10% coins
CYD/Coins
CYD then
$15/40/60
(1) Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for non-emergency conditions cannot be used to satisfy OOPM
(2) Copays will apply once plan CYD has been met.
(3) This High Deductible Health Plan includes a non-embedded individual deductible provision. For individual coverage (self only), the individual deductible and individual
out-of-pocket maximum amounts apply. For family coverage (other than self-only coverage), expenses for all covered family members are combined towards the family
deductible amount. Benefits are payable only after the entire family deductible amount is met.
(4) This High Deductible Health Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in a
family health insurance policy. The plan will begin to pay benefits as soon as one member of the family reaches the individual deductible limit.
FREEDOM BEYOND HMO PLANS (Northern NV Only)
While in northern Nevada, members receive in-network covered benefits from any Prominence HealthFirst HMO provider
(Tier 1). Outside Nevada, members receive in-network covered benefits from any Prominence First Health provider.
Unless of an emergency, no provider coverage is available in southern Nevada. Members are only eligible to receive
out-of-network covered benefits from out-of-state, non-First Health providers. While members are strongly encouraged
to select a primary care physician to help coordinate their care, no referrals are required for members enrolled in a
Freedom Beyond plan. To access the customized Prominence Health Plan First Health provider network, members must
visit www.prominencehealthplan.com.
FREEDOM BEYOND HMO PLANS
PCP/
Specialist
(in-net)
Deductible
In/Out
Inpatient
Emergency
Room
In/Out
Urgent Care
(in-net)
Rx(2)
Freedom
Beyond 1
$15/$40
$500/$1,500
20%/50%
$2,500/$9,500
CYD then
20% Coins
$200 copay
$50 copay
$5/15/30
Freedom
Beyond 2
$20/$40
$850/$2,500
20%/40%
$5,000/$12,500
CYD then
20% Coins
$250 copay
$50 copay
$15/40/60
Freedom
Beyond 3
$25/$50
$1,000/$2,500
30%/50%
$5,000/$12,500
CYD then
30% Coins
$250 copay
$50 copay
$10/30/50
Freedom
Beyond 4
$20/$40
$2,000/$4,000
20%/50%
$6,350/$14,000
CYD then
20% Coins
$200 copay
$50 copay
$10/30/50
Freedom
Beyond 6
$40/$75
$3,500/$4,500
20%/50%
$6,850/$12,500
CYD then
20% Coins
$600 copay
$50 copay
$25/50/75
Freedom
Beyond 7
$30/$65
$3,500/$4,500
30%/40%
$6,850/$13,800
CYD then
30% coins
$350 copay
$50 copay
$25/50/75
Freedom
Beyond 8
$65/$150
$6,400/$6,500
(2x family)
30%/50%
$6,900/$13,800
CYD then
30% Coins
CYD then
30% Coins
$100 copay
$35/$125
CYD then
30% Coins
Plan
(3x family)
Coinsurance
In/Out
OOPM(1)
In/Out
(2x family)
All plans include pediatric dental with coverage for preventive at no charge in-network and 30% out-of-network. Basic/
major and orthodontics subject to the medical plan deductible and covered in-network at 20%/50%/50% and out-ofnetwork at 50%/80%/80.
(1) Deductibles, coinsurance and copayments accrue toward the out-of-pocket maximum (OOPM). The following cannot be used to satisfy the OOPM:
• Penalty for failure to obtain prior authorization; and use of emergency department for non-emergency needs
(2) Specialty pharmacy drugs are paid at a percentage up to the OOPM.
POINT OF SERVICE (POS) PLANS
POS plans combine the low out-of-pocket expenses of an HMO with the greater freedom to choose a Preferred Provider
(PPO) physician from a larger panel of health care professionals, including PHP’s national First Health network.
Prominence Health Plan POS plans are designed as a lower-cost option to our most popular PPO plans. The benefits
available in Tier 2 (PPO) and Tier 3 (any licensed provider) are designed to match many of our current PPO plans so
members have access to the benefits they may currently have on a PPO with the ability to see HMO provider for much
lower costs, often for just a copay. Out-of-pocket expenses under the POS plan will never exceed Tier 2 (PPO) amounts
and some services are covered under the HMO benefit only.
• Tier 1 HMO benefits operate the same way a standard HMO plan operates. In northern Nevada, no referrals are
needed. In southern Nevada, a referral is required through HealthCare Partners, PHP’s HMO provider network.
Typically, benefits have minimal copayments and out-of-pocket costs are lower than the PPO features of these plans.
• Tier 2 PPO benefits offer members the flexibility to see any provider in Prominence Health Plan’s PPO network,
including First Health, without referrals. While many services may be covered by a copayment, there may be
deductibles and higher out-of-pocket costs for the services used.
• Tier 3 out-of-network benefits are paid at the appropriate coinsurance rate once members seek services from
non-contracted providers and have paid their annual deductible.
NEW PLAN SERIES! POS BEYOND PLANS – OFFERED STATEWIDE
Plan
PCP/Specialist
Deductible
(3x family)
Coinsurance
OOPM(1)
(2x family)
Inpatient Copay
Emergency
Room
Urgent
Care
Rx
POS
Beyond 1
$15/$40
$0/$500/$1,500
10%/10%/50%
$2,000/
$2,500/
$9,500
CYD/20% coins HMO;
CYD/20% coins PPO
in-net
$200 copay
$25 HMO;
$50 PPO
in-net
$5/15/30
POS
Beyond 2
$20/$40
$700/$850/
$2,500
20%/20%/40%
$5,000/
$5,000/
$12,500
$500 copay 3 day limit
HMO; CYD/20% coins
PPO in-net
$250 copay
$25 HMO;
$50 PPO
in-net
$15/40/60
POS
Beyond 3
$25/$50
$1,000/$1,000/
$2,500
20%/30%/50%
$3,500/
$5,000/
$12,500
CYD/$750 copay HMO;
CYD/30% coins PPO
in-net
$250 copay
$25 HMO;
$50 PPO
in-net
$10/30/50
POS
Beyond 4
$20/$40
$2,000/$2,000/
$4,000
10%/20%/50%
$4,500/
$6,350/
$14,000
CYD/$0 copay HMO;
CYD/20% coins PPO
in-net
$200 copay
$25 HMO;
$50 PPO
in-net
$10/30/50
POS
Beyond 5
$15/$40 HMO;
$20/$40 PPO
in-net
$2,000/$2,000/
$4,000
10%/10%/30%
$4,500/
$4,500/
$14,000
CYD/10% coins HMO;
CYD/10% coins PPO
in-net
$250 copay
$25 HMO;
$50 PPO
in-net
$15/40/60
POS
Beyond 6
$40/$75
$2,000/$3,500/
$4,500
20%/20%/50%
$6,850/
$6,850/
$12,500
CYD/$2,000 copay HMO;
CYD/20% coins PPO
in-net
$500 copay
$25 HMO;
$50 PPO
in-net
$25/50/75
POS
Beyond 7
$30/$65
$3,000/$3,500/
$4,500
20%/30%/40%
$6,850/
$6,850/
$13,800
CYD/$2,000 copay HMO;
CYD/30% coins PPO
in-net
$350 copay
$25 HMO;
$50 PPO
in-net
$25/50/75
POS
Beyond 8
$65/$150
$6,400 (2X)/
$6,400 (2X)/
$6,500 (3X)
30%/30%/50%
$6,850/
$6,850/
$13,700
CYD/30% coins HMO;
CYD/30% coins PPO
in-net
CYD then
30% coins
$50 HMO;
$100 PPO
in-net
$35/$125
CYD then
30% coins
(1) Deductibles, coinsurance and copays accrue to the out-of-pocket maximum (OOPM). Use of the emergency room for non-emergency conditions cannot be used to satisfy OOPM.
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