HMO Summary of Benefits and Coverage (SBC) (pdf) - Health Net

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Health Net of CA: Health Net HMO Coverage Period: 06/01/2013 – 05/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Covered Members | Plan Type: HMO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-network Provider $30/visit Your Cost If You Use an Out-of-network Provider Not covered Limitations & Exceptions –––––––––––None––––––––––– If you visit a health care provider’s office or clinic If you have a test Specialist visit $45/visit Not covered Requires prior authorization. Other practitioner office visit Not covered Not covered If your medical group authorizes medically necessary acupuncture or chiropractic care, it is covered as a specialist visit (see above). Preventive care/screening/immunization No charge Not covered –––––––––––None––––––––––– Diagnostic test (x-ray, blood work) No charge Not covered Requires referral. Imaging (CT/PET scans, MRIs) $250/ procedure Not covered Requires prior authorization. 2 of 8 CVS_NG/(25N)/DDI/(XMJ)/C0
Health Net of CA: Health Net HMO Coverage Period: 06/01/2013 – 05/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Covered Members | Plan Type: HMO Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com Services You May Need Generic drugs – 30 day supply Generic drugs – 90 day supply Standard & Value Formulary Options Preferred brand drugs – 30 day supply Preferred brand drugs – 90 day supply Standard & Value Formulary Options Non-preferred brand drugs – 30 day supply Non-preferred brand drugs – 90 day supply Standard Formulary Option Only Your Cost If You Use an In-network Provider $7.50/prescription $9.99/prescription 20% coinsurance $41.50/prescription 35% coinsurance $91/prescription Your Cost If You Use an Out-of-network Provider Not covered Not covered Not covered Limitations & Exceptions No charge generic and preferred brand oral contraceptives, Innetwork. Maintenance medications must be filled as a 90 day supply at a CVS/pharmacy or through CVS Caremark Mail Order Pharmacy after two initial 30 day supplies are filled. Under the Standard Formulary Option, if you get a brand drug when a generic is available, you will pay the generic co-pay or coinsurance plus the difference between the discounted cost of the generic and brand drug Non-preferred brand drugs are not available under the Value Formulary Option. There are formulary exclusions. Over-the-counter medications & equipment are excluded. If you have outpatient surgery If you need immediate medical attention Specialty drugs $75/prescription Not covered 30 day supply available through CVS Caremark Specialty Pharmacy only. Facility fee (e.g., ambulatory surgery center) No charge Not covered Requires prior authorization. Physician/surgeon fees No charge Not covered –––––––––––None––––––––––– Emergency room services 10% coinsurance Not covered Coinsurance waived if admitted as hospital inpatient. Emergency medical transportation No charge Not covered –––––––––––None––––––––––– 3 of 8 CVS_NG/(25N)/DDI/(XMJ)/C0
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HMO Summary of Benefits and Coverage (SBC) (pdf) - Health Net

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