Small Business Group Benefits Guide - Rogers Benefit · Health Net built our small business group...

Small Business Group

Jesus Hao,

Health Net

We keep members

informed.

Benefits GuideChoice made simple

Effective September 1, 2011

Commercial

1

Choice Made Simple

Keeping small business growing with the coverage/cost combinations

that fit just right.

Choices for every business, every budgetHealth Net built our small business group

plan portfolio to meet the diverse and growing

needs of your clients. With several price points

and coverage options, we make it simple to

get maximum value for every health care

plan purchase.

• Standard – This line of well-priced,

comprehensive benefit plans gives your

clients the most for their money.

• Value – The Value plans enable clients

to stretch their health care budget with

more employee cost-sharing.

• Health Net Advantage – Our most

economical line is the optimal solution

for clients who haven’t been able to

provide health benefits, as well as those

who need to trim costs.

Have your pick of Standard, Value or

Advantage in HMO, EOA or PPO design.

Our portfolio also offers Standard and

Value HSA-compatible, HRA-eligible

and POS plans.

Tailored network optionsBuilding accessible, quality networks is one

of the things we do best. We’ve translated that

expertise into tailored network options that

give you the most value for the money.

We started with our full HMO network –

one of California’s largest – and created two

subsets: Silver Network and Bronze Network.

By partnering with select providers, our

tailored networks create value and lower

costs for employers. Plus, they give employees

access to trusted health care resources.

Consumer-directed plansWe’re also the one-stop source for your

clients who want to increase employee

involvement in the way they use and pay for

health care services. We offer both Health

Savings Account (HSA)-compatible health

insurance plans and Health Reimbursement

Arrangement (HRA)-eligible plans.

With Health Net, small business owners have

more budget-friendly options to choose from,

which means that more can buy. And when

more clients are buying, you can do more

selling. Turn the page to see how easy it is!

With several price

points and coverage

options, we make

it simple to get

maximum value for

every health care

plan purchase.

2

1 Health Net HMO, EOA, POS and Salud con Health Net HMO plans are offered by Health Net of California, Inc., a subsidiary of Health Net, Inc. Health Net PPO, HSA-compatible PPO insurance plans, HRA-eligible PPO insurance plans, Flex Net and Salud con Health Net PPO and EPO insurance plans are underwritten by Health Net Life Insurance Company.

2 15, 25, 35 and 45 plans are only available with PPO.

Portfolio at a GlanceOur Standard and Value portfolio features

the complete collection of health plan designs:

HMO, Elect Open Access (EOA), PPO,

HSA-compatible PPO and HRA-eligible

PPO insurance plans and POS.1

Price Levels that

Meet Every BudgetOur plans cover a range of price and benefit

levels, so your clients can get the value they

want and deserve. Plan levels are arranged in

decrements of $5 copay levels with percentages

indicating estimated savings between plans.

Plan type

Average savings between copay plans

Average savings between standard & value plans

Average savings between value & advantage plans

Standard HMO 6%12%

Value HMO 10%6%Advantage

HMO 9%

Standard EOA 6%12%

Value EOA 10%6%Advantage

EOA 7%

Standard PPO 10%20%

Value PPO 11%29%Advantage

PPO 12%

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Standard Value

Co

pay

HMO EOA PPO HMO EOA PPO POS10 • • • • • • •15 • • • – – • –20 • • • • • • •25 • • • – – • –30 • • • • • • –35 • • • – – • –40 • • • • • • –45 – – • – – • –50 • • – • • – –

Health Net Advantage

Co

pay

HMO EOA PPO25 • • –35 • • •45 • • •

Standard Value

Ded

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ble

HSA-compatible PPO1500 – •2500 – •3500 – •4000 • –4500 – •

HRA-eligible PPO3000 •5000 •

3

3 References are to federal taxes only. State taxes may apply. Tax information is for general purposes only. For more detailed information about the tax implications of an HSA, please contact a professional tax advisor. The HSA component of our HSA-compatible PPO plans is offered by Bank of America, N.A., as trustee of the HSA. Health Net is not affiliated with Bank of America, N.A.

Finding

the Perfect FitStep 1: Choose a plan designHMO – Plans that require members to

select a primary care physician (PCP). The

PCP coordinates all care and referrals for

the member.

EOA (Elect Open AccessSM) – Our EOA

plans work like an HMO plan with the added

flexibility for members to self-refer to select

providers in our statewide PPO network for

professional services.

PPO – These give insureds the choice of going

to a doctor or hospital in our PPO network

– one of the largest in California with over

63,000 physicians, practitioners and health

professionals and 302 hospitals. Or they can

see a provider not in our network. In general,

insureds get more for less when they use our

PPO network.

POS (Point-of-Service) – Members select a

primary physician like they would in an HMO,

but can choose between two tiers of benefits –

HMO or PPO – each time they access covered

services. Out-of-pocket costs are less when

members use their HMO benefits.

Health Savings Account (HSA)-compatible

PPO plans (part of the Standard-Value

portfolio) – These are a great way for your

clients to give their employees the ability

to use their health care dollars in ways that

work best for them while enjoying tax-

saving opportunities. These plans include

access to our full PPO provider network.

Plus, Health Net has partnered with Bank of

America to offer our members an HSA that’s

easy to administer, quick to set up, and that

comes with a convenient Bank of America

VISA® debit card for account access.3

HRA-eligible (Health Reimbursement

Arrangement) PPO insurance plans – A choice

of two high-deductible PPO health insurance

plans that can be used for self-funding or

wrapping purposes, giving small business

owners even more control over their health

care budget. Among the employer advantages

are no third-party administrator (TPA)

restrictions or limits to the plans clients wrap.

Step 2: Select Standard, Value or AdvantageChoose between Standard, Value and

Advantage for an HMO, EOA or PPO plan.

This choice applies to most of our plan

designs except for HRA-eligible and POS.

Here’s how it works:

• MostbenefitsarethesameforStandard,

Value and Health Net Advantage.

• Thevariablebenefitsare:copayamount,

hospital services, PPO plan deductibles,

prescription brand deductibles and

out-of-pocket maximums.

• Thevariablebenefitsadjustinconsistent

increments with the increase in copay

amounts.

Variable benefits

• Copay (professional services)

• Out-of-pocket maximum

• Hospital services

• Deductibles (PPO only)

• Prescription – brand deductibles

4

Step 3: Pick a deductible or copay• ForourStandardHSA-compatiblePPO

plan, we offer a deductible amount of

$4,000. The plan features 100 percent

in-network coverage for covered services

after the annual deductible is met. And if

the Standard plan doesn’t meet your clients’

needs, we also have Value HSA-compatible

PPO plans at $1,500, $2,500, $3,500 and

$4,500 deductible levels.

• OurHRA-eligiblePPOinsuranceplansare

great cost-saving solutions for your clients

who wish to self-fund or wrap benefit

plans. Groups can pick from two deductible

amounts, $3,000 or $5,000.

• Forallofourotherplans,groupshavea

choice of copay (see the “Portfolio at a glance”

section and plan grids for the options).

Step 4: Pick a network• HMO network – provides over 46,500

physicians and 5,500 pharmacies

across California.

• Silver Network – a select subset of our

regular HMO network offers up to a 25%

savings in parts of our service area. In this

service area, members have access to more

than 6,600 primary care physicians and

14,300 specialists.

• HMO Bronze Network – a select subset

of our Silver Network offers up to a 14%

savings in parts of our service area. In this

service area, members have access to more

than 1,600 primary care physicians and

3,200 specialists.

• PPO network – includes more than

63,000 physicians and 5,500 pharmacies

across California.

Silver Network service areaAvailable in all or parts of Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Clara, Stanislaus and Ventura counties.

Bronze Network service areaAvailable in parts of Los Angeles, San Bernardino and San Diego counties.

Herminia Escobedo,

Health Net

We get members

what they need.

5

4Available in Orange and select ZIP codes of Los Angeles, Riverside, San Bernardino and San Diego counties.

5Available in Los Angeles, Orange and Ventura counties.

6Available in Mexicali, Rosarito, Tecate and Tijuana.

Package deals: Tailored for choice

Enhanced Choice, Silver Choice, Bronze Choice

With the Choice packages, members receive

the same high quality of care, but at an even

lower price. Employers pay one fixed premium

amount while giving employees the option of

choosing from any of the plans in the small

group portfolio.

Hn Options, Hn Options + Silver, Hn Options + Bronze

The Hn Options packages give employees

a choice of 12 (for five to nine employees)

or 17 (for 10 to 50 employees) Health Net

plans that may be offered alongside another

carrier, including Kaiser Permanente, as long

as the employer meets a few participation

requirements.

See our Underwriting Guidelines for

package specifics.

Cross-border coverage: SaludOur affordable and innovative cross-border

plan continues to bring an affordable health

care option tailored to the unique needs of

the Latino community. Salud plans feature:

• Accesstomorethan3,600doctorsand

specialists in our Salud HMO Network.4

Or, there are also more than 1,300

physicians and specialists in our Salud

PPO Network5 and more than 200 doctors

in the SIMNSA Network6 in México.

• Cross-borderaccesstocarewithouta

referral via the Sistemas Médicos Nacionales,

S.A. de C.V. (SIMNSA) network of providers

in Mexico (Tijuana, Mexicali, Rosarito

and Tecate).

• Coverageforeligibledependentslivingin

Mexico, within 50 miles of the California

border, who may enroll and receive care

exclusively from SIMNSA providers.

• Urgentcarefacilitiesforafter-hourscare

(in select medical groups).

• Ratesrunapproximately30–40percentlower

than similar commercial plans in the market

that don’t offer cross-border coverage.

The Salud plans are a great way to attract new

group clients in the counties of Los Angeles,

Orange and San Diego, plus select ZIP codes

in San Bernardino and Riverside counties. Call

your Health Net sales representative to get

service area ZIP codes.

Dual Network option: Mix and matchPick any number of Silver Choice or Bronze Choice tailored network plans. Clients first select Silver or Bronze and then offer as many plans as they’d like within that portfolio.

Offer up to four specially designed full network HMO plans alongside. Each one comes with the familiar HMO benefits, full network access,

health-promoting wellness resources, and more. So all your clients have to do is pick the one – or ones – that fits their business best.

To qualify for Dual Network, clients need to have 2–50 employees and 75 percent participation with a minimum of two employees enrolled.

1

2

6

HMO PortfolioBenefit description2 HMO 20 (Dual Network) HMO 30 (Dual Network) HMO 40 (Dual Network)

Standard (5NK)

Standard (5NL)

Value (5NM)

Value (5NJ)

Plan maximumsOut-of-pocket maximum

$2,000 single / $4,000 family




Lifetime medical benefit maximum No maximum No maximum No maximum No maximum

Professional servicesOffice visit

$20 copay

$30 copay

$30 copay

$40 copay

Specialist consultation $30 copay $40 copay $50 copay $60 copay

Preventive care services3 Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy5 $20 copay $30 copay $30 copay $40 copay

Self-injectable drugs 30% 30% 30% 30%

Hospital servicesInpatient hospital facility services (includes maternity)

$250 copay/day (3-day copay max/admit)


30%

40%

Outpatient facility services (other than surgery)

20% 30% 30% 40%

Outpatient surgery (hospital or outpatient surgery center charges only)

$250 copay $500 copay 30% 40%

Skilled nursing facility Days 1–10: Covered in full Days 11–100: $25/day

Days 1–10: Covered in full Days 11–100: $25/day



Emergency servicesProfessional services

Covered in full

Covered in full

Covered in full

Covered in full

Emergency room facility (copay waived if admitted)

$150 copay $150 copay $150 copay $150 copay

Urgent care facility $50 copay $50 copay $50 copay $50 copay

Ambulance services (ground and air) $100 copay $100 copay $100 copay $100 copay

Behavioral services6

Severe mental health (outpatient/inpatient)

$20 copay / $250 copay/day (3-day copay max/admit)


$30 copay / 30%

$40 copay / 40%

Non-severe mental health (outpatient/inpatient)

$30 copay (20 visits/year) / $250 copay/day (3-day copay max/admit) (30 days/year)


$35 copay (20 visits/year) / 30% (30 days/year)


Chemical dependency rehabilitation (outpatient/inpatient)

Not covered Not covered Not covered Not covered

Acute care detoxification $250 copay/day (3-day copay max/admit)


30% 40%

Other servicesDurable medical equipment

50% ($2,000 maximum per calendar year)




Orthotics and prosthetics Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available

Prescription drug coverage8

Brand name calendar year deductible (per member)

No deductible

No deductible

$200

$250

Prescription drugs (up to a 30-day supply)9

$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans. Dual Network HMO plans also available as stand-alone plans.

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Plan footnotes found on pages 50–53.

Benefit description2 HMO 20 (Dual Network) HMO 30 (Dual Network) HMO 40 (Dual Network)

Standard (5NK)

Standard (5NL)

Value (5NM)

Value (5NJ)








$20 copay

$30 copay

$30 copay

$40 copay

Specialist consultation $30 copay $40 copay $50 copay $60 copay


X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full


Self-injectable drugs 30% 30% 30% 30%




30%

40%


20% 30% 30% 40%


$250 copay $500 copay 30% 40%






Covered in full

Covered in full

Covered in full

Covered in full


$150 copay $150 copay $150 copay $150 copay


Ambulance services (ground and air) $100 copay $100 copay $100 copay $100 copay





$30 copay / 30%

$40 copay / 40%







Not covered Not covered Not covered Not covered



30% 40%








Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

No deductible

$200

$250


$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

8

HMO Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans. All HMO plans available in the full, Silver or Bronze Networks.1

Benefit description2 HMO 10 HMO 15 HMO 20 HMO 25

Standard (1EJ) (1FV) (1GE)

Value (1EN) (1FZ) (1GJ)

Standard (5SG) (5SN) (5SU)

Standard (1EK) (1FW) (1GF)

Value (1EP) (1GB) (1GK)

Standard (5SH) (5SP) (5SV)








Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum

Professional servicesOffice visit (including specialist consultation)

$10 copay

$10 copay

$15 copay

$20 copay

$20 copay

$25 copay

Preventive care services3 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy5 $10 copay $10 copay $15 copay $20 copay $20 copay $25 copay

Self-injectable drugs 30% 30% 30% 30% 30% 30%


Covered in full

10%



20%



Covered in full 10% 15% 20% 20% 25%


Covered in full 10% $250 copay $250 copay 20% $500 copay








Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full


$100 copay $100 copay $150 copay $100 copay $100 copay $150 copay

Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay

Ambulance services (ground and air)




$10 copay / Covered in full

$10 copay / 10%



$20 copay / 20%



$30 copay (20 visits/year) / Covered in full (30 days/year)







Not covered Not covered Not covered Not covered Not covered Not covered

Acute care detoxification Covered in full 10% $250 copay/day (3-day copay max/admit)


20% $500 copay/day (3-day copay max/admit)








Orthotics and prosthetics Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$100

No deductible

No deductible

$150

No deductible


$10 / $25 / $50 $10 / $25 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

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Standard (1EJ) (1FV) (1GE)

Value (1EN) (1FZ) (1GJ)

Standard (5SG) (5SN) (5SU)

Standard (1EK) (1FW) (1GF)

Value (1EP) (1GB) (1GK)

Standard (5SH) (5SP) (5SV)








Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum


$10 copay

$10 copay

$15 copay

$20 copay

$20 copay

$25 copay

Preventive care services3 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy5 $10 copay $10 copay $15 copay $20 copay $20 copay $25 copay

Self-injectable drugs 30% 30% 30% 30% 30% 30%


Covered in full

10%



20%



Covered in full 10% 15% 20% 20% 25%


Covered in full 10% $250 copay $250 copay 20% $500 copay








Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full



Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay






$10 copay / 10%



$20 copay / 20%










Not covered Not covered Not covered Not covered Not covered Not covered











Orthotics and prosthetics Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$100

No deductible

No deductible

$150

No deductible


$10 / $25 / $50 $10 / $25 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

10

HMO Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans. All HMO plans available in the full, Silver or Bronze Networks.1


Standard (1EL) (1FX) (1GG)

Value (1EQ) (1GC) (1GL)

Standard (5SJ) (5SQ) (5SW)

Standard (1EM) (1FY) (1GH)

Value (1ER) (1GD) (1GM)

Standard (5NS) (5BP) (5PD)

Value (5NT) (5PC) (5PE)









Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum


$30 copay

$30 copay

$35 copay

$40 copay

$40 copay

$50 copay

$50 copay

Preventive care services3 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy5 $30 copay $30 copay $35 copay $40 copay $40 copay $50 copay $50 copay

Self-injectable drugs 30% 30% 30% 30% 30% 30% 30%



30%


$1,000 copay/day (3-day copay max/admit)

40%


50%


30% 30% 35% 40% 40% 50% 50%


$500 copay 30% $750 copay $1,000 copay 40% $1,500 copay 50%









Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full


$100 copay $100 copay $150 copay $100 copay $100 copay $200 copay $300 copay

Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay






$30 copay / 30%


$40 copay / $1,000 copay/day (3-day copay max/admit)

$40 copay / 40%


$50 copay / 50%





$40 copay (20 visits/year) / $1,000 copay/day (3-day copay max/admit) (30 days/year)





Not covered Not covered Not covered Not covered Not covered Not covered Not covered




40% $1,500 copay/day (3-day copay max/admit)

50%









Orthotics and prosthetics Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$200

No deductible

No deductible

$250

No deductible

$250


$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

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Standard (1EL) (1FX) (1GG)

Value (1EQ) (1GC) (1GL)

Standard (5SJ) (5SQ) (5SW)

Standard (1EM) (1FY) (1GH)

Value (1ER) (1GD) (1GM)

Standard (5NS) (5BP) (5PD)

Value (5NT) (5PC) (5PE)









Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum


$30 copay

$30 copay

$35 copay

$40 copay

$40 copay

$50 copay

$50 copay

Preventive care services3 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy5 $30 copay $30 copay $35 copay $40 copay $40 copay $50 copay $50 copay

Self-injectable drugs 30% 30% 30% 30% 30% 30% 30%



30%



40%


50%


30% 30% 35% 40% 40% 50% 50%


$500 copay 30% $750 copay $1,000 copay 40% $1,500 copay 50%









Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full



Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay






$30 copay / 30%



$40 copay / 40%


$50 copay / 50%










Not covered Not covered Not covered Not covered Not covered Not covered Not covered




40% $1,500 copay/day (3-day copay max/admit)

50%









Orthotics and prosthetics Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$200

No deductible

No deductible

$250

No deductible

$250


$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

12

HMO Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Advantage plans. All HMO plans available in the full, Silver or Bronze Networks.1

Benefit description2 Advantage HMO 25 (1JZ) (1JV) (1JT) Advantage HMO 35 (1KB) (1JW) (1JU) Advantage HMO 45 (1JY) (1JR) (1JS)Plan maximumsOut-of-pocket maximum




Lifetime medical benefit maximum No maximum No maximum No maximum


$25 copay

$35 copay

$45 copay

Preventive care services3 Covered in full Covered in full Covered in full

X-ray and laboratory procedures4 Covered in full Covered in full Covered in full

Rehabilitation therapy5 $25 copay $35 copay $45 copay

Self-injectable drugs 30% 30% 30%


25%

35%

45%


25% 35% 45%


25% 35% 45%





Covered in full

Covered in full

Covered in full


$100 copay $100 copay $100 copay

Urgent care facility $50 copay $50 copay $50 copay





$25 copay / 25%

$35 copay / 35%

$45 copay / 45%


$30 copay (20 visits/year) / 25% (30 days/year) $35 copay (20 visits/year) / 35% (30 days/year) $45 copay (20 visits/year) / 45% (30 days/year)


Not covered Not covered Not covered

Acute care detoxification 25% 35% 45%





Orthotics and prosthetics Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20%

Acupuncture, chiropractic services7 Optional rider available Optional rider available Optional rider available



$200

$250

$300


$15 / $40 / $60 $15 / $40 / $60 $15 / $40 / $60

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Benefit description2 Advantage HMO 25 (1JZ) (1JV) (1JT) Advantage HMO 35 (1KB) (1JW) (1JU) Advantage HMO 45 (1JY) (1JR) (1JS)Plan maximumsOut-of-pocket maximum






$25 copay

$35 copay

$45 copay


X-ray and laboratory procedures4 Covered in full Covered in full Covered in full




25%

35%

45%


25% 35% 45%


25% 35% 45%





Covered in full

Covered in full

Covered in full








$25 copay / 25%

$35 copay / 35%

$45 copay / 45%















$200

$250

$300


$15 / $40 / $60 $15 / $40 / $60 $15 / $40 / $60

14

EOA Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans. All EOA plans available in Silver Network.1

Benefit description2 EOA 10 EOA 15 EOA 20 EOA 25 EOA 30

Standard (1ES) (1GN)

Value (1EW) (1GS)

Standard (5TB) (5TH)

Standard (1ET) (1GP)

Value (1EX) (1GT)

Standard (5TC) (5TJ)

Standard (1EU) (1GQ)

Value (1EY) (1GU)










Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum

Professional services3

Office visit (including specialist consultation)

HMO: $10 copay PPO: $25 copay








Preventive care services4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Rehabilitation therapy7 HMO: $10 copay PPO: $25 copay (12 visits per calendar year)

HMO: $10 copay PPO: $25 copay (12 visits per calendar year)







Self-injectable drugs 30% 30% 30% 30% 30% 30% 30% 30%

Hospital services8

Inpatient hospital facility services (includes maternity)

Covered in full

10%



20%



30%


Covered in full 10% 15% 20% 20% 25% 30% 30%


Covered in full 10% $250 copay $250 copay 20% $500 copay $500 copay 30%










Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full


$100 copay $100 copay $150 copay $100 copay $100 copay $150 copay $100 copay $100 copay

Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay






$10 copay / 10%



$20 copay / 20%



$30 copay / 30%


$30 copay (20 visits/ year) / Covered in full (30 days/year)






$35 copay (20 visits/ year) / $500 copay/day (3-day copay max/admit) (30 days/year)



Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered



20% $500 copay/day (3 day copay max/admit)


30%

Other servicesDurable medical equipment8









Orthotics and prosthetics8 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20% 20% 20% 20%

Acupuncture, chiropractic services10 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$100

No deductible

No deductible

$150

No deductible

No deductible

$200


$10 / $25 / $50 $10 / $25 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

15


Benefit description2 EOA 10 EOA 15 EOA 20 EOA 25 EOA 30

Standard (1ES) (1GN)

Value (1EW) (1GS)

Standard (5TB) (5TH)

Standard (1ET) (1GP)

Value (1EX) (1GT)

Standard (5TC) (5TJ)

Standard (1EU) (1GQ)

Value (1EY) (1GU)










Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum No maximum











Preventive care services4 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full









Self-injectable drugs 30% 30% 30% 30% 30% 30% 30% 30%

Hospital services8


Covered in full

10%



20%



30%


Covered in full 10% 15% 20% 20% 25% 30% 30%


Covered in full 10% $250 copay $250 copay 20% $500 copay $500 copay 30%










Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full



Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay






$10 copay / 10%



$20 copay / 20%



$30 copay / 30%


$30 copay (20 visits/ year) / Covered in full (30 days/year)






$35 copay (20 visits/ year) / $500 copay/day (3-day copay max/admit) (30 days/year)



Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered



20% $500 copay/day (3 day copay max/admit)


30%










Orthotics and prosthetics8 Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full


Acupuncture, chiropractic services10 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

$100

No deductible

No deductible

$150

No deductible

No deductible

$200


$10 / $25 / $50 $10 / $25 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

EO

A

16

EOA Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans. All EOA plans available in Silver Network.1

Benefit description2 EOA 35 EOA 40 EOA 50

Standard (5TD) (5TK)

Standard (1EV) (1GR)

Value (1EZ) (1GV)

Standard (5NX) (5PL)

Value (5NW) (5PK)







Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum








Preventive care services4 Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full Covered in full Covered in full






Self-injectable drugs 30% 30% 30% 30% 30%

Hospital services8




40%


50%


35% 40% 40% 50% 50%


$750 copay $1,000 copay 40% $1,500 copay 50%







Covered in full

Covered in full

Covered in full

Covered in full

Covered in full


$150 copay $100 copay $100 copay $200 copay $300 copay

Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay







$40 copay / 40%


$50 copay / 50%








Not covered Not covered Not covered Not covered Not covered

Acute care detoxification $750 copay/day (3 day copay max/admit)


40% $1,500 copay/day (3 day copay max/admit)

50%







Orthotics and prosthetics8 Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20%

Acupuncture, chiropractic services10 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

No deductible

$250

No deductible

$250


$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

17


Benefit description2 EOA 35 EOA 40 EOA 50

Standard (5TD) (5TK)

Standard (1EV) (1GR)

Value (1EZ) (1GV)

Standard (5NX) (5PL)

Value (5NW) (5PK)







Lifetime medical benefit maximum No maximum No maximum No maximum No maximum No maximum








Preventive care services4 Covered in full Covered in full Covered in full Covered in full Covered in full

X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full Covered in full Covered in full






Self-injectable drugs 30% 30% 30% 30% 30%

Hospital services8




40%


50%


35% 40% 40% 50% 50%


$750 copay $1,000 copay 40% $1,500 copay 50%







Covered in full

Covered in full

Covered in full

Covered in full

Covered in full



Urgent care facility $50 copay $50 copay $50 copay $50 copay $50 copay







$40 copay / 40%


$50 copay / 50%








Not covered Not covered Not covered Not covered Not covered

Acute care detoxification $750 copay/day (3 day copay max/admit)


40% $1,500 copay/day (3 day copay max/admit)

50%







Orthotics and prosthetics8 Covered in full Covered in full Covered in full Covered in full Covered in full

Diabetic supplies 20% 20% 20% 20% 20%

Acupuncture, chiropractic services10 Optional rider available Optional rider available Optional rider available Optional rider available Optional rider available



No deductible

No deductible

$250

No deductible

$250


$15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50 $15 / $30 / $50

EO

A

18

EOA Portfolio Please note: All highlighted plan boxes reflect standardized benefits between Advantage plans. All EOA plans available in Silver Network.1

Benefit description2 Advantage EOA 25 (1KD) (1KH) Advantage EOA 35 (1KE) (1KJ) Advantage EOA 45 (1KC) (1KG)



$4,000 single / $8,000 family $5,000 single / $10,000 family








X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full

Rehabilitation therapy7 HMO: $25 copay / PPO: $45 copay(12 visits per calendar year)

HMO: $35 copay / PPO: $55 copay(12 visits per calendar year)



Hospital services8


25%

35%

45%


25% 35% 45%


25% 35% 45%





Covered in full

Covered in full

Covered in full








$25 copay / 25% $35 copay / 35% $45 copay / 45%






Other servicesDurable medical equipment8 50% ($2,000 maximum per calendar year) 50% ($2,000 maximum per calendar year)


Orthotics and prosthetics8 Covered in full Covered in full Covered in full





$200 $250

$300


$15 / $40 / $60 $15 / $40 / $60 $15 / $40 / $60

19


Benefit description2 Advantage EOA 25 (1KD) (1KH) Advantage EOA 35 (1KE) (1KJ) Advantage EOA 45 (1KC) (1KG)











X-ray and laboratory procedures5,6 Covered in full Covered in full Covered in full

Rehabilitation therapy7 HMO: $25 copay / PPO: $45 copay(12 visits per calendar year)




Hospital services8


25%

35%

45%


25% 35% 45%


25% 35% 45%





Covered in full

Covered in full

Covered in full








$25 copay / 25% $35 copay / 35% $45 copay / 45%






Other servicesDurable medical equipment8 50% ($2,000 maximum per calendar year) 50% ($2,000 maximum per calendar year)


Orthotics and prosthetics8 Covered in full Covered in full Covered in full





$200 $250

$300


$15 / $40 / $60 $15 / $40 / $60 $15 / $40 / $60

EO

A

20

POS PortfolioBenefit description1 POS 10 (1FB) POS 20 (1FC)

Plan maximumsCalendar year deductible

HMO PPO2 Out-of-network3.4 HMO PPO2 Out-of-network3.4

No deductible

$250 single / $500 family

$500 single / $1,000 family

No deductible



Out-of-pocket maximum $1,500 single / $3,000 family $3,000 single / 2 per family $6,000 single / 2 per family $2,000 single / $4,000 family $3,500 single / 2 per family $7,000 single / 2 per family

Lifetime medical benefit maximum No maximum No maximum


$10 copay

$20 copay

50%

$20 copay

$30 copay

50%

Preventive care services5 Covered in full Covered in full Not covered Covered in full Covered in full Not covered

X-ray and laboratory procedures Covered in full 10% 50% Covered in full 20%7 50%7

Rehabilitation therapy6 $10 copay 10% 50% $20 copay 20%7 50%7

(12 visits per calendar year, PPO and OON combined) (12 visits per calendar year, PPO and OON combined)

Self-injectable drugs 30% 30% 50% 30% 30%7 50%7


Covered in full

10%7

50% ($600 maximum allowable/day)7

$250 copay/day (3-day copay maximum)

20%7


($250 deductible per calendar year, PPO and OON combined)8 ($250 deductible per calendar year, PPO and OON combined)8


Covered in full 10%7 50% (50% maximum allowable)7 20% 20%7 50% (50% maximum allowable)7


Covered in full 10%7 50% (50% maximum allowable)7 $250 copay 20%7 50% (50% maximum allowable)7



10%7 50% ($250 maximum allowable/day)7





Covered in full

10%

Covered in full

20%

50%


$100 copay $100 copay + 10% $100 copay $100 copay + 20% $100 + 50%

Urgent care facility $50 copay $50 copay + 10% $50 copay $50 copay + 20% $50 + 50%

Ambulance services (ground and air) $100 copay $50 copay + 10%7 $50 copay + 50%7 $100 copay $50 copay + 20%7 $50 copay + 50%7




Not covered

$20 copay / $250/day (3-day copay max/admit)

Not covered


$30 copay (20 visits per calendar year) / Covered in full (30 days per calendar year)

Not covered $30 copay (20 visits per calendar year) / $250/day (3-day copay max/admit) (30 days per calendar year)

Not covered



Not covered Not covered / Not covered Not covered

Acute care detoxification Covered in full Not covered $250 copay/day (3-day copay max/admit)

Not covered



50%7 ($2,000 maximum per calendar year,

PPO and OON combined)




Orthotics Covered in full 10%7 50%7 Covered in full 20%7 50%7

Prosthetics Covered in full 10%7 50%7 Covered in full 20%7 50%7

Diabetic supplies 20% 20%7 50%7 20% 20%7 50%7

Chiropractic services11 $10 copay $20 copay (12 visits per calendar year)

Not covered $20 copay $30 copay (12 visits per calendar year)

Not covered

Acupuncture11 $10 copay Not covered $20 copay Not covered Not covered


Calendar year deductible (per member) No deductible

No deductible

$100

No deductible

No deductible

$100


$10 / $25 / $50 50% $15 / $30 / $50 50%

21

PO

SP

OS


Benefit description1 POS 10 (1FB) POS 20 (1FC)


HMO PPO2 Out-of-network3.4 HMO PPO2 Out-of-network3.4

No deductible



No deductible



Out-of-pocket maximum $1,500 single / $3,000 family $3,000 single / 2 per family $6,000 single / 2 per family $2,000 single / $4,000 family $3,500 single / 2 per family $7,000 single / 2 per family



$10 copay

$20 copay

50%

$20 copay

$30 copay

50%

Preventive care services5 Covered in full Covered in full Not covered Covered in full Covered in full Not covered

X-ray and laboratory procedures Covered in full 10% 50% Covered in full 20%7 50%7

Rehabilitation therapy6 $10 copay 10% 50% $20 copay 20%7 50%7


Self-injectable drugs 30% 30% 50% 30% 30%7 50%7


Covered in full

10%7


$250 copay/day (3-day copay maximum)

20%7




Covered in full 10%7 50% (50% maximum allowable)7 20% 20%7 50% (50% maximum allowable)7


Covered in full 10%7 50% (50% maximum allowable)7 $250 copay 20%7 50% (50% maximum allowable)7








Covered in full

10%

Covered in full

20%

50%


$100 copay $100 copay + 10% $100 copay $100 copay + 20% $100 + 50%

Urgent care facility $50 copay $50 copay + 10% $50 copay $50 copay + 20% $50 + 50%

Ambulance services (ground and air) $100 copay $50 copay + 10%7 $50 copay + 50%7 $100 copay $50 copay + 20%7 $50 copay + 50%7




Not covered

$20 copay / $250/day (3-day copay max/admit)

Not covered



Not covered $30 copay (20 visits per calendar year) / $250/day (3-day copay max/admit) (30 days per calendar year)

Not covered



Not covered Not covered / Not covered Not covered

Acute care detoxification Covered in full Not covered $250 copay/day (3-day copay max/admit)

Not covered








Orthotics Covered in full 10%7 50%7 Covered in full 20%7 50%7

Prosthetics Covered in full 10%7 50%7 Covered in full 20%7 50%7

Diabetic supplies 20% 20%7 50%7 20% 20%7 50%7

Chiropractic services11 $10 copay $20 copay (12 visits per calendar year)

Not covered $20 copay $30 copay (12 visits per calendar year)

Not covered

Acupuncture11 $10 copay Not covered $20 copay Not covered Not covered


Calendar year deductible (per member) No deductible

No deductible

$100

No deductible

No deductible

$100


$10 / $25 / $50 50% $15 / $30 / $50 50%

22

PPO PortfolioBenefit description1 PPO 10 PPO 15


Standard (1FN) Value (1KK) Standard (5QH) Value (5QJ)

PPO2 Out-of-network3 PPO2 Out-of-network3 PPO2 Out-of-network3 PPO2 Out-of-network3

No deductible








Out-of-pocket maximum (does not include calendar year deductible)

$2,500 single / 2 per family










$10 copay

40%

$10 copay

40%

$15 copay

50%

$15 copay

50%

Specialist consultation $10 copay 40% $10 copay 40% $25 copay 50% $25 copay 50%

Preventive care services4 Covered in full Not covered Covered in full Not covered Covered in full Not covered Covered in full Not covered

X-ray and laboratory procedures5 10% 40% 20% 40% 15% 50% 25% 50%

Rehabilitation therapy5,6 10% 40% 20% 40% 15% 50% 25% 50%(12 visits per calendar year, PPO and OON combined)

(12 visits per calendar year, PPO and OON combined)



Hospital services5


10%

40%

20%

40%

15%

50% ($600 maximum allowable per day)

25%

50%

($250 deductible per calendar year, PPO and OON combined)7



10% 40% 20% 40% 15% 50% 25% 50%


10% 40% 20% 40% 15% 50% 25% 50%

Skilled nursing facility 10% 40% ($250 maximum allowable per day)

20% 40% ($250 maximum allowable per day)




$10 copay

$10 copay

$15 copay

$15 copay


$100 copay + 10% $100 copay + 20% $200 copay + 15% $250 copay + 25%

Urgent care facility $50 copay + 10% $50 copay + 20% $50 copay + 15% $50 copay + 25%

Ambulance services (ground and air)5 $50 copay + 10% $50 copay + 40% $50 copay + 20% $50 copay + 40% $50 copay + 15% $50 copay + 50% $50 copay + 25% $50 copay + 50%



$10 copay / 10%

40%

$10 copay / 20%

40%

$15 copay / 15%

50%

$15 copay / 25%

50%

Non-severe mental health (outpatient/inpatient)9

10% 40% 20% 40% 15% 50% 25% 50%

Chemical dependency rehabilitation (outpatient/inpatient)9

10% 40% 20% 40% 15% 50% 25% 50%

Acute care detoxification 10% 40% 10% 40% 15% 50% 25% 50%($250 maximum allowable per day,

PPO and OON combined)($250 maximum allowable per day,





10%

40%

20%

40%

15%

50%

25%

50%

($3,000 maximum per calendar year, PPO and OON combined)




Orthotics and prosthetics5 10% 40% 20% 40% 15% 50% 25% 50%


Chiropractic services $10 copay (12 visits per calendar year)

Not covered $10 copay (12 visits per calendar year)



Not covered

Acupuncture 10% 40% 20% 40% 15% 50% 25% 50%(12 visits per calendar year, PPO and OON combined; $25 maximum payable per visit)

(12 visits per calendar year, PPO and OON combined; $25 maximum payable per visit)




Calendar year deductible (per insured) No deductible

$100

$100 brand deductible

$100

No deductible

$100


$100


$10 / $25 / $50 50% $10 / $25 / $50 50% $10 / $25 / $50 50% $10 / $25 / $50 50%

Specialty drugs (most self-injectables) 30% ($250 copay maximum per prescription)

Not covered 30% ($250 copay maximum per prescription)



Not covered

Please note: All highlighted plan boxes reflect standardized benefits between Standard and Value plans.

23

PP

O


Benefit description1 PPO 10 PPO 15


Standard (1FN) Value (1KK) Standard (5QH) Value (5QJ)


No deductible



















$10 copay

40%

$10 copay

40%

$15 copay

50%

$15 copay

50%








Hospital services5


10%

40%

20%

40%

15%

50% ($600 maximum allowable per day)

25%

50%




10% 40% 20% 40% 15% 50% 25% 50%


10% 40% 20% 40% 15% 50% 25% 50%

Skilled nursing facility 10% 40% ($250 maximum allowable per day)





$10 copay

$10 copay

$15 copay

$15 copay







$10 copay / 10%

40%

$10 copay / 20%

40%

$15 copay / 15%

50%

$15 copay / 25%

50%


10% 40% 20% 40% 15% 50% 25% 50%


10% 40% 20% 40% 15% 50% 25% 50%







10%

40%

20%

40%

15%

50%

25%

50%











Not covered

Acupuncture 10% 40% 20% 40% 15% 50% 25% 50%(12 visits per calendar year, PPO and OON combined; $25 maximum payable per visit)






$100


$100

No deductible

$100


$100


$10 / $25 / $50 50% $10 / $25 / $50 50% $10 / $25 / $50 50% $10 / $25 / $50 50%





Not covered

24



Standard (1FP) Value (1FS) Standard (5QD) Value (5QE)











$3,000 single / 2 per family $6,000 single / 2 per family $3,500 single / 2 per family $7,000 single / 2 per family $3,500 single / 2 per family $7,000 single / 2 per family $5,000 single / 2 per family $10,000 single / 2 per family



$20 copay

50%

$20 copay

50%

$25 copay

50% $25 copay

50%








Hospital services5


10%

50% ($600 maximum allowable/day)

20%


25% 50% ($600 maximum allowable/day)







10% 50% (50% maximum allowable)













Skilled nursing facility 10% 50% ($250 maximum allowable/day)









$20 copay








$20 copay / 10%

50% / 50% ($600 maximum allowable/day)

$20 copay / 20%


$25 copay / 25%


$25 copay / 35% 50% / 50% ($600 maximum allowable/day)






10% 50% 20% 50% 25% 50% 35% 50%


10% 50% 20% 50% 25% 50% 35% 50%

Acute care detoxification 10% 50% 20% 50% 25% 50% 35% 50%($250 maximum allowable/day,

PPO and OON combined)($250 maximum allowable/day,





10%

50%

20%

50%

25%

50%

35%

50%











Not covered

Acupuncture 10% 50% 20% 50% 25% 50% 35% 50%(12 visits per calendar year, PPO and OON combined;

$25 maximum payable per visit)(12 visits per calendar year, PPO and OON combined;



$25 maximum payable per visit)



$100


$100 No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered


25

PP

O



Standard (1FP) Value (1FS) Standard (5QD) Value (5QE)














$20 copay

50%

$20 copay

50%

$25 copay

50% $25 copay

50%








Hospital services5


10%


20%































$20 copay








$20 copay / 10%


$20 copay / 20%


$25 copay / 25%








10% 50% 20% 50% 25% 50% 35% 50%


10% 50% 20% 50% 25% 50% 35% 50%







10%

50%

20%

50%

25%

50%

35%

50%











Not covered








$100


$100 No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered


26



Standard (1FQ) Value (1FT) Standard (5QG) Value (5QB)














$30 copay 50%

$30 copay 50%

$35 copay

50%

$35 copay

50%




Rehabilitation therapy5,6 20% 50% 30% 50% 35% 50% 45% 50%(12 visits per calendar year,PPO and OON combined)

(12 visits per calendar year,PPO and OON combined)



Hospital services5



30%


35%


45%




























Emergency servicesProfessional services $30 copay $30 copay $35 copay $35 copay








$30 copay / 30%









20% 50% 30% 50% 35% 50% 45% 50%


20% 50% 30% 50% 35% 50% 45% 50%







20%

50%

30%

50%

35%

50%

45%

50%

($1,000 maximum per calendar year,PPO and OON combined)










Not covered








$100


$100

No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered


27

PP

O



Standard (1FQ) Value (1FT) Standard (5QG) Value (5QB)














$30 copay 50%

$30 copay 50%

$35 copay

50%

$35 copay

50%








Hospital services5



30%


35%


45%




































$30 copay / 30%









20% 50% 30% 50% 35% 50% 45% 50%


20% 50% 30% 50% 35% 50% 45% 50%







20%

50%

30%

50%

35%

50%

45%

50%











Not covered








$100


$100

No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered


28


Standard (1FR) Value (1FU) Standard (5QF) Value (5QC)














$40 copay 50%

$40 copay 50%

$45 copay

50%

$45 copay

50%








Hospital services5



50%


45%


50%
































Ambulance services (ground and air)5 $50 copay + 40% $50 copay + 50% $50 copay + 50% $50 copay + 45% $50 copay + 50% $50 copay + 50% $50 copay + 50%




$40 copay / 50%









40% 50% 50% 50% 45% 50% 50% 50%


40% 50% 50% 50% 45% 50% 50% 50%







40%

50%

50%

50%

45%

50%

50%

50%











Not covered








$100


$100

No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered


29

PP

O



Standard (1FR) Value (1FU) Standard (5QF) Value (5QC)














$40 copay 50%

$40 copay 50%

$45 copay

50%

$45 copay

50%








Hospital services5



50%


45%


50%




































$40 copay / 50%









40% 50% 50% 50% 45% 50% 50% 50%


40% 50% 50% 50% 45% 50% 50% 50%







40%

50%

50%

50%

45%

50%

50%

50%











Not covered








$100


$100

No deductible

$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%





Not covered

30

PPO Portfolio Plan footnotes found on pages 50–53.

Benefit description1 Advantage PPO 35 (5ZQ) Advantage PPO 45 (5ZR)PPO2 Out-of-network3 PPO2 Out-of-network3

Plan maximumsCalendar year deductible $3,000 single / $6,000 family


Out-of-pocket maximum(includes calendar year deductible)







$35 copay 50%

$45 copay 50%

Specialist consultation $45 copay 50% $55 copay 50%

Preventive care services4 Covered in full Not covered Covered in full Not covered

X-ray and laboratory procedures5 40% 50% 50% 50%

Rehabilitation therapy5,6 40% 50% 50% 50%(12 visits per calendar year,PPO and OON combined)


Hospital services5



50%





Outpatient surgery (hospital charges only)



Outpatient surgery (ambulatory surgery center charges only)





Emergency servicesProfessional services $35 copay $45 copay


$150 copay + 40% $150 copay + 50%

Urgent care facility $50 copay + 40% $50 copay + 50%

Ambulance services (ground and air)5 $50 copay + 40% $50 copay + 50% $50 copay + 50% $50 copay + 50%




$45 copay / 50%



40% 50% 50% 50%


40% 50% 50% 50%

Acute care detoxification 40% 50% 50% 50%($250 maximum allowable/day,




40%

50%

50%

50%



Orthotics and prosthetics5 40% 50% 50% 50%




Not covered

Acupuncture 40% 50% 50% 50%(12 visits per calendar year, PPO and OON combined; $25 maximum payable per visit)



Brand name calendar year deductible (per insured)


$100


$100


$15 / $30 / $50 50% $15 / $30 / $50 50%



Not covered

31

Standard HSA Portfolio Plan footnotes found on pages 50–53.

Benefit description1 Standard HSA 4000 (1FJ)PPO2 Out-of-network3

Plan maximumsCalendar year deductible (For family coverage, the enrolled employee and dependents must collectively pay the family amount before Health Net begins to pay.)

$4,000 single (employee-only coverage) /$8,000 family (employee and dependent coverage)

Out-of-pocket maximum (includes deductible and copays)

$5,950 single (employee-only coverage) / $11,900 family (employee and dependent coverage)


Lifetime medical benefit maximum No maximum


$0 copay (deductible not waived) 50%

Preventive care services4 Covered in full Not covered

X-ray and laboratory procedures5 0% 50%

Rehabilitation therapy5,6 0% 50%


Hospital services5








Emergency servicesProfessional services $0 copay (deductible not waived)

50%

Emergency room facility 0% 50%

Urgent care facility 0% 50%

Ambulance services (ground and air)5 0% 50%





0% 50%


0% 50%

Acute care detoxification 0% 50%

($250 maximum allowable/day)


0%

50%


Orthotics and prosthetics5 0% 50%

Diabetic supplies 0% 50%

Chiropractic services $0 copay (deductible not waived, 12 visits per calendar year)

Not covered

Acupuncture 0% 50%



Calendar year deductible (per insured) Subject to annual deductible


$10 / $25 / $50 50%

Specialty drugs (most self-injectables) 30% Not covered

STAN

DA

RD

HSA

32

Value HSA PortfolioBenefit description1 Value HSA 1500 (1FD) Value HSA 2500 (1FF) Value HSA 3500 (1FH) Value HSA 4500 (1FK)



$1,500 single (employee-only coverage) /

$3,000 family (employee and dependent coverage)







Out-of-pocket maximum (includes deductible)











$10 copay (deductible not waived)

40% $20 copay (deductible not waived)


50%


50%







Hospital services5


20% 40%

20%


30%


50%






20% 40% 20% 50% (50% maximum allowable)



















40% $20 copay

(deductible not waived)

50% $30 copay


50% $40 copay


50%


$100 copay + 20% $100 + 40% $100 copay + 20% $100 + 50% $100 copay + 30% $100 + 50% $100 copay + 50%

Urgent care facility $50 copay + 20% $50 + 40% $50 copay + 20% $50 + 50% $50 copay + 30% $50 + 50% $50 copay + 50%


Behavioral servicesSevere mental health (outpatient/inpatient)

$10 copay / 20% 40% / 40%

$20 copay / 20%








20% 40% 20% 50% 30% 50% 50% 50%


20% 40% 20% 50% 30% 50% 50% 50%

Acute care detoxification 20% 40% 20% 50% 30% 50% 50% 50%($250 maximum allowable/day) ($250 maximum allowable/day) ($250 maximum allowable/day,




20%

40%

20%

50%

30%

50%

50%

50%








Not covered $20 copay (deductible not waived, 12 visits per calendar year)



Not covered







Calendar year deductible (per insured)

Subject to annual deductible





$10 / $25 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%

Specialty drugs (most self-injectables) 30% Not covered 30% Not covered 30% Not covered 30% Not covered

33


VA

LUE

HSA

Benefit description1 Value HSA 1500 (1FD) Value HSA 2500 (1FF) Value HSA 3500 (1FH) Value HSA 4500 (1FK)











Out-of-pocket maximum (includes deductible)














50%


50%







Hospital services5


20% 40%

20%


30%


50%

























40% $20 copay


50% $30 copay


50% $40 copay


50%


$100 copay + 20% $100 + 40% $100 copay + 20% $100 + 50% $100 copay + 30% $100 + 50% $100 copay + 50%

Urgent care facility $50 copay + 20% $50 + 40% $50 copay + 20% $50 + 50% $50 copay + 30% $50 + 50% $50 copay + 50%



$10 copay / 20% 40% / 40%

$20 copay / 20%








20% 40% 20% 50% 30% 50% 50% 50%


20% 40% 20% 50% 30% 50% 50% 50%

Acute care detoxification 20% 40% 20% 50% 30% 50% 50% 50%($250 maximum allowable/day) ($250 maximum allowable/day) ($250 maximum allowable/day,




20%

40%

20%

50%

30%

50%

50%

50%











Not covered













$10 / $25 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50% $15 / $30 / $50 50%

Specialty drugs (most self-injectables) 30% Not covered 30% Not covered 30% Not covered 30% Not covered

34

HRA PortfolioBenefit description1 HRA 3000 (5UG) HRA 5000 (5UH)

PPO2 Out-of-network3 PPO2 Out-of-network3

All benefits including Rx are subject to the deductible






Out-of-pocket maximum (includes deductibles, coinsurance and copays)





50% (deductible not waived) Not covered 50% (deductible not waived)

Not covered



Rehabilitation therapy5,6 20% 40% 20% 40%


Hospital services5

Inpatient hospital facility services (includes maternity) 20% 40% ($600 maximum allowable/day)

20%


Outpatient facility services (other than surgery) 20% 40% (50% maximum allowable) 20% 40% (50% maximum allowable)


20% 40% (50% maximum allowable) 20% 40% (50% maximum allowable)

Skilled nursing facility 20% 40% ($250 maximum allowable/day) 20% 40% ($250 maximum allowable/day)




40%

Emergency room facility (copay waived if admitted) $100 copay + 20% $100 + 40% $100 copay + 20% $100 + 40%

Urgent care facility $50 copay + 20% $50 + 40% $50 copay + 20% $50 + 40%



Severe mental health (outpatient/inpatient) 20% Not covered 20% Not covered

Non-severe mental health (outpatient/inpatient) 20%7 Not covered 20%7 Not covered


20%7 Not covered 20%7 Not covered

Acute care detoxification 20% ($250 maximum allowable/day) Not covered 20% ($250 maximum allowable/day) Not covered

Other servicesDurable medical equipment and orthotics5

20%

40%

20%

40%

($3,000 maximum per calendar year, PPO and OON combined) ($3,000 maximum per calendar year, PPO and OON combined)


Chiropractic services $20 (12 visits per calendar year) Not covered $20 (12 visits per calendar year) Not covered

Acupuncture 20% 40% 20% 40%



Prescription drug coverage8 Subject to calendar year medical deductible (per insured) Subject to calendar year medical deductible (per insured)

Prescription drugs (up to a 30-day supply)9 $10 / $25 / $50 50% $10 / $25 / $50 50%

Specialty drugs (most self-injectables) 30% Not covered 30% Not covered

35


Benefit description1 HRA 3000 (5UG) HRA 5000 (5UH)PPO2 Out-of-network3 PPO2 Out-of-network3

All benefits including Rx are subject to the deductible






Out-of-pocket maximum (includes deductibles, coinsurance and copays)





50% (deductible not waived) Not covered 50% (deductible not waived)

Not covered



Rehabilitation therapy5,6 20% 40% 20% 40%


Hospital services5

Inpatient hospital facility services (includes maternity) 20% 40% ($600 maximum allowable/day)

20%


Outpatient facility services (other than surgery) 20% 40% (50% maximum allowable) 20% 40% (50% maximum allowable)


20% 40% (50% maximum allowable) 20% 40% (50% maximum allowable)

Skilled nursing facility 20% 40% ($250 maximum allowable/day) 20% 40% ($250 maximum allowable/day)




40%

Emergency room facility (copay waived if admitted) $100 copay + 20% $100 + 40% $100 copay + 20% $100 + 40%




Severe mental health (outpatient/inpatient) 20% Not covered 20% Not covered

Non-severe mental health (outpatient/inpatient) 20%7 Not covered 20%7 Not covered


20%7 Not covered 20%7 Not covered

Acute care detoxification 20% ($250 maximum allowable/day) Not covered 20% ($250 maximum allowable/day) Not covered

Other servicesDurable medical equipment and orthotics5

20%

40%

20%

40%

($3,000 maximum per calendar year, PPO and OON combined) ($3,000 maximum per calendar year, PPO and OON combined)


Chiropractic services $20 (12 visits per calendar year) Not covered $20 (12 visits per calendar year) Not covered

Acupuncture 20% 40% 20% 40%



Prescription drug coverage8 Subject to calendar year medical deductible (per insured) Subject to calendar year medical deductible (per insured)

Prescription drugs (up to a 30-day supply)9 $10 / $25 / $50 50% $10 / $25 / $50 50%


HR

A

36

Salud con Health Net PortfolioBenefit description1 Salud HMO y Más 15 (1HT)

SIMNSA Network2

(Mexico members)Salud network(California members)

SIMNSA Network2

(self-referral for California members)

Plan maximumsOut-of-pocket maximum3

$1,500 single / $3,000 two-party / $4,500 family



$5 copay

$15 copay $5 copay


X-ray and laboratory procedures Covered in full Covered in full Covered in full


Self-injectable drugs Covered in full Covered in full Covered in full


Covered in full

$250 per admission copay

Covered in full


Covered in full 20% Covered in full



Skilled nursing facility(100 days per calendar year)



Covered in full

Covered in full

Covered in full




Ambulance services (ground and air) Covered in full $50 copay Covered in full



$5 copay / Covered in full7 $15 copay / Covered in full

$5 copay / Covered in full7


$5 copay (20 visits/year) / Covered in full (20 days/year)7

$15 copay / Covered in full $5 copay (20 visits/year) / Covered in full (20 days/year)7





Acute care detoxification 20%7 Covered in full 20%7


Covered in full

Covered in full

Covered in full


Diabetic supplies Covered in full Covered in full Covered in full

Acupuncture, chiropractic services Not covered Optional rider available8 Not covered

Prescription drug coverage


No deductible

No deductible

No deductible


$5 copay $5 / $15 / $35 $5 copay

37

Benefit description1 Salud HMO y Más 25 (1HU)SIMNSA Network2

(Mexico members)Salud network (California members)

SIMNSA Network2








$5 copay

$25 copay $5 copay


X-ray and laboratory procedures Covered in full Covered in full5 Covered in full


Self-injectable drugs Covered in full Covered in full Covered in full


Covered in full

$250/day (4-day copay maximum)

Covered in full








Covered in full

Covered in full

Covered in full




Ambulance services (ground and air) Covered in full $100 copay Covered in full











Acute care detoxification 20% (20 days per year)7 Covered in full 20% (20 days per year)7


Covered in full

30%

Covered in full


Diabetic supplies Covered in full Covered in full Covered in full

Acupuncture, chiropractic services Not covered Optional rider available8 Not covered



No deductible

$250

No deductible


$5 copay $10 / $35 / $50 $5 copay

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Benefit description1 Salud HMO y Más 35 (1KF) Salud Mexico HMO (1HX)SIMNSA Network2 (Mexico members)

Salud network(California members)

SIMNSA Network2


SIMNSA Network only2








$5 copay

$35 copay $5 copay

$5 copay


X-ray and laboratory procedures Covered in full Covered in full5 Covered in full Covered in full


Self-injectable drugs Covered in full Covered in full Covered in full Covered in full


Covered in full


Covered in full

Covered in full


Covered in full 20% Covered in full Covered in full






Covered in full

Covered in full

Covered in full

Covered in full


$10 copay $100 copay $10 copay $10 copay (in Mexico) /$50 copay (outside Mexico)


Ambulance services (ground and air) Covered in full $100 copay Covered in full Covered in full (air ambulance not covered)














Acute care detoxification 20% (20 days per year)7 Covered in full 20% (20 days per year)7 20%7


Covered in full

30%

Covered in full

Covered in full


Diabetic supplies Covered in full Covered in full Covered in full Covered in full

Acupuncture, chiropractic services Not covered Optional rider available8 Not covered Not covered



No deductible

$250

No deductible

No deductible


$5 copay $10 / $35 / $50 $5 copay $5 copay

Salud con Health Net Portfolio

39

Benefit description1 Salud HMO y Más 35 (1KF) Salud Mexico HMO (1HX)SIMNSA Network2 (Mexico members)


SIMNSA Network2


SIMNSA Network only2








$5 copay

$35 copay $5 copay

$5 copay


X-ray and laboratory procedures Covered in full Covered in full5 Covered in full Covered in full


Self-injectable drugs Covered in full Covered in full Covered in full Covered in full


Covered in full


Covered in full

Covered in full








Covered in full

Covered in full

Covered in full

Covered in full


$10 copay $100 copay $10 copay $10 copay (in Mexico) /$50 copay (outside Mexico)


Ambulance services (ground and air) Covered in full $100 copay Covered in full Covered in full (air ambulance not covered)














Acute care detoxification 20% (20 days per year)7 Covered in full 20% (20 days per year)7 20%7


Covered in full

30%

Covered in full

Covered in full


Diabetic supplies Covered in full Covered in full Covered in full Covered in full

Acupuncture, chiropractic services Not covered Optional rider available8 Not covered Not covered



No deductible

$250

No deductible

No deductible


$5 copay $10 / $35 / $50 $5 copay $5 copay


Josefina Bravo,

Health Net

We’re dedicated

to member health

and wellness.

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Benefit description1 Salud PPO (1HW)SIMNSA Network2 (Mexico members)


Out-of-network3



Not applicable

$100 single / 2 per family


Out-of-pocket maximum $1,000 single / $2,000 family $2,000 single / $4,000 family $10,000 single / $10,000 family



$5 copay

$15 copay 50%

Preventive care services4 Covered in full Covered in full 50%

X-ray and laboratory procedures5 10% 20% 50%

Rehabilitation therapy5,6 10% 20% ($25 maximum per visit) 50% ($25 maximum per visit)

Self-injectable drugs5 $5 copay See Specialty drugs See Specialty drugs

Hospital services5


10% $250 per admission deductible9 + 20%

$250 per admission deductible9 + 50% ($380 maximum/day)


10% $250 deductible9 + 20% $250 deductible9 + 50% (50% maximum allowable)


10% $250 deductible9 + 20% $250 deductible9 + 50% (50% maximum allowable)

Skilled nursing facility Not covered $250 deductible9 + 20% $250 deductible9 + 50% ($150 maximum allowable/day)


10%

20%

50%


$25 deductible + 10% $50 deductible + 20% $100 deductible + 50%

Urgent care facility $25 deductible + 10% $50 deductible + 20% $100 deductible + 50%

Ambulance services (ground and air)5 $20 deductible + 10% (air not covered)

$50 deductible + 20% 50%



$5 copay / 10% $15 copay / $2509 + 20% 50% / $2509 + 50% ($380 maximum allowable/day)


$5 copay + 10% / 10%8 $30 copay + 20% / 20% $30 copay + 50% / 50%8


$5 copay + 10% / Not covered8 $30 copay + 20% / Not covered $30 copay + 50% / Not covered8

Acute care detoxification 10% 20% + $250 per admit9 50% + $250 per admit9

($380 max allowable/day)


10%

20%

50%

Orthotics and prosthetics 10% 20% 50%


Acupuncture, chiropractic services Not covered


Prescription drugs dispensed by SIMNSA

$5 copay

Not applicable

$5 copay

Prescription drugs dispensed by a Health Net participating pharmacy10

Not applicable $10 / $35 / 50% Not covered

Specialty drugs (most self-injectables) Not covered 30% ($250 copay maximum per prescription)

Not covered

Salud con Health Net Portfolio

41

Benefit description1 Salud EPO (1HV)SIMNSA Network2 Salud network

Plan maximumsCalendar year deductible No deductible

Out-of-pocket maximum No deductible $1,500 single / $4,500 family



$5 copay $15 copay

Preventive care services4 Covered in full Covered in full

Specialist consultation $5 copay $35 copay

X-ray and laboratory procedures5 Covered in full Covered in full

Rehabilitation therapy6 $5 copay $15 copay

Self-injectable drugs Covered in full See Specialty drugs

Hospital services5

Inpatient hospital facility services Covered in full $250 per admission deductible


Covered in full 20%


Covered in full 20%

Skilled nursing facility Not covered 20% (100 days per calendar year)


Covered in full

Covered in full


$10 copay $100 copay

Urgent care facility $10 copay $15 copay

Ambulance services (ground and air)5 Covered in full (air ambulance not covered)

$50 copay




$15 copay / $250 per admit deductible


$5 copay / Covered in full8 $15 copay / $250 per admit deductible

(20 days per calendar year; inpatient maximum SIMNSA and Salud combined,

shared with chemical dependency rehab)


$5 copay / Covered in full8 $15 copay / $250 per admit deductible

(20 days per calendar year; inpatient maximum SIMNSA and Salud combined,

shared with non-severe mental health)

Acute care detoxification Covered in full8 $250 per admit deductible

(3-day maximum per calendar year, SIMNSA and Salud combined)


Covered in full

Covered in full

Orthotics and prosthetics5 Covered in full Covered in full

Diabetic supplies5 Covered in full Covered in full

Acupuncture, chiropractic services Not covered Not covered



No deductible

No deductible


$5 copay $10 / $35 / 50%

Specialty drugs (most self-injectables) See Self-injectable drugs 30% ($250 copay maximum per prescription)


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Flex Net Portfolio Plan footnotes found on pages 50–53.

Benefit description1 Flex Net Indemnity2 (1KL)

Plan maximumsCalendar year deductible $300 single / $900 family





20%

Preventive care services3 Covered in full

X-ray and laboratory procedures4 20%

Rehabilitation therapy4,5 20% (60 visits per calendar year)

Hospital services4


20%


20%


20%

Skilled nursing facility 20% (60 days per calendar year)


20%

Emergency room facility 20%

Urgent care facility 20%

Ambulance services (ground and air) 20% (Ground: max distance 75 miles per incident / Air: $750 max per incident)


20% / 20%

Non-severe mental health6 (outpatient/inpatient)

50% / 50%


50% / 50%

Acute care detoxification 50% (3 days per calendar year)


20%

Orthotics and prosthetics4 20%

Diabetic supplies 20%

Chiropractic services 20% (15 visits per calendar year, $25 maximum payable per visit)

Acupuncture Not covered

Prescription drug coverageCalendar year deductible (per insured) $75 brand-name deductible

Prescription drugs (up to a 30-day supply)

20%


43

Benefit description2 Options HMO 25 (1HY) (1HZ) (1JB) Options HMO 35 (1JC) (1JD) (1JE)Plan maximumsOut-of-pocket maximum





$25 copay

$35 copay


X-ray and laboratory procedures4 Covered in full Covered in full

Rehabilitation therapy5 $25 copay $35 copay

Self-injectable drugs 30% 30%


20%

30%


20% 30%


20% 30%

Skilled nursing facility Days 1–10: Covered in fullDays 11–100: $25/day

Days 1–10: Covered in fullDays 11–100: $25/day


Covered in full

Covered in full




Ambulance services (ground and air) $100 copay $100 copay



$25 copay / 20% $35 copay / 30%


$30 (20 visits per calendar year) /20% (30 days per calendar year)



Not covered Not covered





Orthotics and prosthetics Covered in full Covered in full


Acupuncture, chiropractic services7 Optional rider available Optional rider available



$150

$200


$15 / $30 / $50 $15 / $30 / $50

Options HMO PortfolioPlease note: HMO plans are available with Silver Network and Bronze Network.1


Hn O

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MO

44

Please note: EOA plans are available with Silver Network.1

Plan footnotes found on pages 50–53.Options EOA PortfolioBenefit description2 Options EOA 25 (1JF) (1JG) Options EOA 35 (1JH) (1JJ)Plan maximumsOut-of-pocket maximum









X-ray and laboratory procedures5,6 Covered in full Covered in full



Self-injectable drugs 30% 30%


20%

30%

Outpatient facility services (other than surgery)8

20% 30%


20% 30%

Skilled nursing facility Days 1–10: Covered in fullDays 11–100: $25/day

Days 1–10: Covered in fullDays 11–100: $25/day


Covered in full

Covered in full




Ambulance services (ground and air) $100 copay $100 copay



$25 copay / 20% $35 copay / 30%





Not covered Not covered





Orthotics and prosthetics8 Covered in full Covered in full


Acupuncture, chiropractic services9 Optional rider available Optional rider available



$150

$200


$15 / $30 / $50 $15 / $30 / $50

45

Options PPO Portfolio Plan footnotes found on pages 50–53.

Benefit description1 Options PPO 250 (1JK)PPO2 Out-of-network3





$3,500 single / 2 per family $7,000 single / 2 per family



$25 copay 50%





Hospital services5












$25 copay


$100 copay + 20%

Urgent care facility $50 copay + 20%

Ambulance services (ground and air)5 $50 copay + 20% $50 copay + 50%





20% 50%


20% 50%




20%

50%



Diabetic supplies5 20% 50%

Chiropractic services $25 copay (12 visits per calendar year) Not covered

Acupuncture 20% 50%



Calendar year deductible (per insured) $150 brand deductible $100


$15 / $30 / $50 50%

Specialty drugs (most self-injectables) 30% ($250 copay maximum per prescription) Not covered

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46

Plan footnotes found on pages 50–53.Options PPO PortfolioBenefit description1 Options PPO 500 (1JL)

PPO2 Out-of-network3








$35 copay 50%





Hospital services5


30%










Emergency servicesProfessional services $35 copay


$100 copay + 30%







30% 50%


30% 50%




30%

50%





Acupuncture 30% 50%



Calendar year deductible (per insured) $200 brand deductible

$100


$15 / $30 / $50 50%


47

Options PPO PortfolioBenefit description1 Options PPO 1500 (1JM)

PPO2 Out-of-network3








$25 copay 50%





Hospital services5












$25 copay


$100 copay + 30%







30% 50%


30% 50%




30%

50%





Acupuncture 30% 50%



Calendar year deductible (per insured) $150 brand deductible $100


$15 / $30 / $50 50%



Hn O

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48


Benefit description1 Options PPO 1750 (1JN)PPO2 Out-of-network3








$35 copay 50%





Hospital services5


40%










Emergency servicesProfessional services $35 copay


$100 copay + 40%







40% 50%


40% 50%




40%

50%





Acupuncture 40% 50%



Calendar year deductible (per insured) $200 brand deductible

$100


$15 / $30 / $50 50%


49


Benefit description1 Options PPO 3000 (HSA-compatible) (1JP) Options PPO 4000 (HSA-compatible) (1JQ)


PPO2 Out-of-network3 PPO2 Out-of-network3


$6,000 family (employee and dependent coverage



Out-of-pocket maximum (includes calendar year deductible)







50%



Rehabilitation therapy5,6 30% 50% 40% 50%(12 visits per calendar year,PPO and OON combined)


Hospital services5



40%


















50% $35 copay


50%


$100 copay + 30% $100 + 50% $100 copay + 40% $100 + 50%




$25 / 30% 50% / 50% ($600 maximum allowable/day)

$35 / 40%





30% 50% 40% 50%


30% 50% 40% 50%

Acute care detoxification 30% 50% 40% 50%($250 maximum allowable/day) ($250 maximum allowable/day)


30%

50%

40%

50%



Orthotics and prosthetics5 30% 50% 40% 50%

Diabetic supplies5 30% 50% 40% 50%



Not covered

Acupuncture 30% 50% 40% 50%(12 visits per calendar year, PPO and OON combined;








$15 / $30 / $50 50% $15 / $30 / $50 50%


Hn O

PTIO

NS P

PO

50

HMO 1 The Silver Network is an affordable network alternative offered in all or parts of Kern, Los Angeles, Orange, San Bernardino,

San Diego, San Francisco, Santa Clara, Stanislaus, Riverside and Ventura counties. The Bronze Network is a network alternative offered in parts of Los Angeles, San Bernardino and San Diego counties. Ask if these networks are available in your area.

2 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for terms and conditions of coverage. The three plan codes are: Full network; Silver Network; Bronze Network.

3 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 4 Complex radiology (includes CT, SPECT, PET and MRI) requires a $100 copay. 5 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 6 All mental health and chemical dependency services are provided or contracted through Managed Health Network (MHN).

Please contact MHN for details. 7 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with the HMO plan shown above. Features of

Health Net’s chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year. 8 Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copay. For details regarding a specific

drug, go to www.healthnet.com. 9 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

EOA 1 The Silver Network is an affordable network alternative offered in all or parts of Kern, Los Angeles, Orange, San Bernardino,

San Diego, San Francisco, Santa Clara, Stanislaus, Riverside and Ventura counties. Ask if this network is available in your area. 2 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for

terms and conditions of coverage. The two plan codes are: Full network; Silver Network. 3 For the PPO level, self-referral to a PPO network physician. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Complex radiology (includes CT) requires a $100 copay under HMO and PPO. MRI, MUGA, PET and SPECT services are not

covered through PPO level. 6 Under Elect Open Access, radiographic X-ray and laboratory services will be covered only when provided or coordinated by your

primary care physician and approved by the PPG/IPA, except when provided at a PPO physician’s office or contracted PPO lab or facility. 7 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 8 Under Elect Open Access, inpatient hospital and professional services, durable medical equipment and orthotics and prosthetics

are covered when provided or coordinated by the primary care physician only and approved by the PPG/IPA. Inpatient care and outpatient services are not covered on the PPO level.

9 All mental health and chemical dependency services are provided or contracted through Managed Health Network (MHN). Please contact MHN for details.

10 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with the EOA plan shown above. Features of Health Net’s chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year.

11 Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copay. For details regarding a specific drug, go to www.healthnet.com.

12 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

POS 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for

terms and conditions of coverage. 2 Member pays the negotiated rate, which is the rate the participating or preferred providers have agreed to accept for providing a

covered service.

3 Please refer to the Certificate of Insurance (COI) for out-of-network reimbursement methodology.

4 The 50% coinsurance through the OON level will apply towards the member’s out-of-pocket maximum.

5 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services.

6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy.

7 Some services require prior certification. If prior certification is not acquired, the benefits are reduced to 50%. 8 This deductible is required only for the first inpatient hospital or skilled nursing facility admission each calendar year. Once the

deductible is satisfied, no deductible is required for subsequent admissions in the same calendar year. This deductible is in addition to the plan calendar year deductible.

9 Once the outpatient surgery deductible is satisfied, no deductible is required for subsequent outpatient surgeries in the same calendar year. This deductible is in addition to the plan calendar year deductible.

10 All mental health and chemical dependency services are provided or contracted through Managed Health Network (MHN). Please contact MHN for details.

11 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with the POS plan shown above through the HMO level. Features of Health Net’s chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year.


13 The three prescription drug tiers are: Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

Note: Health Net’s 2010 ratio of premium costs to health services paid for Small Business HMO and PPO health plans were 76.3% and 92.8% respectively.Footnotes

51

PPO 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance

for terms and conditions of coverage. 2 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a

covered service. 3 Please refer to the Certificate of Insurance (COI) for out-of-network reimbursement methodology. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Some services require prior certification. If prior certification is not acquired, the benefits are reduced to 50%. 6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 7 This deductible is only required for the first inpatient hospital or skilled nursing facility admission each calendar year. The

deductible does not apply to inpatient detoxification or to inpatient care for non-severe mental illness. Once the deductible is satisfied, no deductible is required for subsequent admissions in the same calendar year. This deductible is in addition to the plan calendar year deductible and applies to the OOPM.

8 Once the outpatient surgery deductible is satisfied, no deductible is required for subsequent outpatient surgeries in the same calendar year. This deductible is in addition to the plan calendar year deductible and applies to the OOPM.

9 Inpatient care for non-severe mental illness and inpatient chemical dependency rehabilitation is limited to a maximum allowable of $250 each day. Outpatient care for non-severe mental illness and outpatient chemical dependency rehabilitation has a maximum amount payable of $25 per visit.



Standard HSA 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance

(COI) for terms and conditions of coverage. 2 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a

covered service. 3 Please refer to the Certificate of Insurance (COI) for out-of-network reimbursement methodology. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Some services require prior certification. If prior certification is not acquired, the benefits are reduced to 50%. 6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 7 Inpatient care for non-severe mental illness and inpatient chemical dependency rehabilitation is limited to a maximum allowable

of $250 each day. Outpatient care for non-severe mental illness and outpatient chemical dependency rehabilitation has a maximum amount payable of $25 per visit.

8 Prescription drugs filled through mail order (up to a 90-day supply). For details regarding a specific drug, go to www.healthnet.com. 9 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

Value HSA 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance



deductible does not apply to inpatient detoxification or to inpatient care for non-severe mental illness. Once the deductible is satisfied, no deductible is required for subsequent admissions in the same calendar year. This deductible is in addition to the plan calendar year deductible and applies to the out-of-pocket maximum (OOPM).

8 Once the outpatient surgery deductible is satisfied, no deductible is required for subsequent outpatient surgeries in the same calendar year. This deductible is in addition to the plan calendar year deductible and applies to the OOPM.



52

HRA 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance

for terms and conditions of coverage. 2 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 3 Please refer to the Certificate of Insurance (COI) for out-of-network reimbursement methodology. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Some services require prior certification. Without prior certification, the benefits are reduced to 50%. An additional $250 penalty

deductible is applied for each inpatient admit that does not receive prior certification and an additional $50 penalty deductible is applied for outpatient visits for specified services. Refer to your Certificate of Insurance (COI) for additional information.

6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 7 Inpatient care for non-severe mental illness and inpatient chemical dependency rehabilitation is limited to a maximum allowable

of $250 each day. Outpatient care for non-severe mental illness and outpatient chemical dependency rehabilitation has a maximum amount payable of $25 per visit.


Salud con Health Net HMO y Más and Salud Mexico 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for

terms and conditions of coverage. 2 Out-of-network providers, facilities or pharmacies in Mexico (other than those in the SIMNSA Network) are not covered by

this plan. 3 The OOPM is combined for SIMNSA networks in Mexico and California. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Complex radiology (includes CT, SPECT, PET and MRI) requires a $100 copay. 6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 7 Mental health and substance abuse services must be provided by a SIMNSA provider. 8 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with the HMO plan shown above. Features of

Health Net’s chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year. 9 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

Salud con Health Net PPO/EPO 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance

(COI) for terms and conditions of coverage. 2 Out-of-network providers, facilities or pharmacies in Mexico (other than those in the SIMNSA Network) are not covered by

this plan.

3 Please refer to the Certificate of Insurance (COI) for out-of-network reimbursement methodology. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services.

5 Some services require prior certification. If prior certification is not acquired, the benefits are reduced to 50%.

6 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy.

7 For non-severe inpatient services, there is a $250 maximum allowable through Health Net Salud Network and OON. Outpatient mental health care and outpatient chemical dependency rehabilitation are limited to 20 visits for each member in a calendar year through SIMNSA, PPO and OON combined.

8 Mental health and substance abuse services must be provided by a SIMNSA provider.

9 A $250 deductible is required for each inpatient hospital admission and each outpatient service, including surgery. The deductible will apply when emergency services are performed.


Hn HMO Options 1 The HMO Silver Network is an affordable network alternative offered in all or parts of Kern, Los Angeles, Orange, San Bernardino,

San Diego, San Francisco, Riverside, Santa Clara, Stanislaus and Ventura counties. The Bronze Network is a network alternative offered in parts of Los Angeles, San Bernardino and San Diego counties. Ask your employer if these networks are available to you.

2 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for terms and conditions of coverage. The three plan codes are: Full network; Silver Network; Bronze Network.

3 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 4 Complex radiology (includes CT, SPECT, PET, MUGA and MRI) requires a $100 copay. 5 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 6 All mental health and chemical dependency services are provided or contracted through Managed Health Network (MHN).

Please contact MHN for details. 7 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with these HMO plans. Features of Health Net’s

chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year. 8 Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copay. For details regarding a specific

drug, go to www.healthnet.com. 9 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand nonformulary.

53

Hn EOA Options 1 The EOA Silver Network is an affordable network alternative offered in all or parts of Kern, Los Angeles, Orange, San Bernardino,

San Diego, San Francisco, Riverside, Santa Clara, Stanislaus and Ventura counties. Ask your employer if this network is available to you.

2 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Evidence of Coverage for terms and conditions of coverage. The two plans codes are: Full network; Silver Network.

3 For the PPO level, self-referral to a PPO network physician. 4 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 5 Under Elect Open Access, radiographic X-ray and laboratory services will be covered only when provided or coordinated by

your primary care physician and approved by the PPG/IPA, except when provided at a PPO physician’s office or contracted PPO lab or facility.

6 Complex radiology (includes CT) requires a $100 copay under HMO and PPO. MRI, MUGA, PET and SPECT services are not covered through PPO level.

7 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 8 Under Elect Open Access, inpatient hospital and professional services, durable medical equipment and orthotics and prosthetics

are covered when provided or coordinated by the primary care physician only and approved by the PPG/IPA. Inpatient care and outpatient services are not covered on the PPO level.

9 Chiropractic and/or acupuncture rider coverage is available as an optional benefit with the EOA plan shown above. Features of Health Net’s chiropractic coverage include a $10 per visit copay and up to 20 visits per calendar year.



Hn PPO OPTIONS 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance



deductible does not apply to inpatient detoxification or to inpatient care for non-severe mental illness. Once the deductible is satisfied, no deductible is required for subsequent admissions in the same calendar year. This deductible is in addition to the plan calendar year deductible.

8 Once the outpatient surgery deductible is satisfied, no deductible is required for subsequent outpatient surgeries in the same calendar year. This deductible is in addition to the plan calendar year deductible.




Flex Net 1 This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance

(COI) for terms and conditions of coverage. Flex Net is only available to out-of-area (OOA) subscribers, subject to standard OOA guidelines. Health Net must be the sole carrier.

2 Please refer to the Certificate of Insurance (COI) for reimbursement methodology. 3 Includes annual preventive physical, newborn and well-child care, well-woman exams, preventive lab and X-ray services. 4 Some services require prior certification. If prior certification is not acquired, the benefits are reduced to 50%. 5 Includes physical, speech, occupational, cardiac and pulmonary rehabilitation therapy. 6 Inpatient mental health and inpatient chemical dependency rehabilitation are limited to a combined maximum of 30 days for each

member in a calendar year. Outpatient mental health and outpatient chemical dependency rehabilitation has a maximum amount payable of $50 per visit.

6025248 CA82560 (7/11) Health Net of California, Inc., Health Net Life Insurance Company and Managed Health Network are subsidiaries of Health Net, Inc. Health Net, Health Net Elect and Salud con Health Net are registered service marks of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.

For more information please contact

Health Net

PO Box 9103

Van Nuys, CA 91409-9103

Broker Services

1-800-448-4411, option 4

Small Business Group Sales and Service Administration

1-800-447-8812 (English)

1-877-891-9050 (Cantonese)

1-877-339-8596 (Korean)

1-877-891-9053 (Mandarin)

1-800-331-1777 (Spanish)

1-877-891-9051 (Tagalog)

1-877-339-8621 (Vietnamese)

Telecommunications device for the hearing and speech impaired

1-800-995-0852

Other optionsCoverage for individuals and families

1-800-909-3447

Coverage for family members over 65 years of age

1-800-944-7287

Coverage for children in a low-income household

1-800-327-0502

Coverage for businesses with 50+ employees

1-800-448-4411, option 4

www.healthnet.com

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