Health Net PPO Health Insurance Plans Individuals Families CA 2011

8/7/2019 Health Net PPO Health Insurance Plans Individuals Families CA 2011

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PPO HEALTH insurAncEPLAns FOr inDiViDuALsAnD FAMiLiEsHealth insurance and more – for the way you live

E ective January 1, 2011

INDIVIDUAL & FAMILY PLANS

www.HealthNetworkInsurance.com

http://www.healthnetworkinsurance.com/ca-get-quote






health net plans it your budget, it your li eeasy x 7 – the advantages of a health net insurance plan ...........3

helpful definitions ............................................................................................4

ppo .............................................................................................................................5

• Standard PPO..................................................................................................................................................6

• HSA-compatible PPO.....................................................................................................................................7

• Dental and Vision............................................................................................................................................8

suppleMental terM life insurance .............................................................9

BENEFITS AT-A-GLANCE FOR QUICK COMPARISON......................................10

suMMary of Benefits

• Optimum Advantage HSA...........................................................................................................................11

• ValueNet........................................................................................................................................................12

• Dental and Vision....................................................................................................................................13–16

no-Cost eXtrasdecision poWer ® ................................................................................................18

• Health coaching............................................................................................................................................19

• Online programs ...........................................................................................................................................19

SELF-SERVICE AT www.HEALTHNET.COM......................................................19

applying or health net Coverage

TAKE A TEST DRIVE (AT www.HEALTHNET.COM)..........................................21

hoW to apply ......................................................................................................21

IMPORTANT THINGS TO KNOw...................................................................22–23

important in ormation. The health bene ts and coverage matrices on pages 11–13 are included to helpyou compare coverage bene ts. Be sure to revie the plan descriptions, so you kno hich providers you canchoose to get health care services.

Inside the back pocket is the disclosure document e’re required to give everyone before they enroll in one ofour health insurance plans. This document explains general insurance plan exclusions and limitations, and is meantto be read ith this brochure. If there is a difference bet een these documents and the Insurance Policy, theInsurance Policy takes precedence.If you do not have a Health Net PPO Insurance Plans Outline of Coverage and Exclusions and Limitationsi th b k k t l t f th i d H lth N t A t

PART1

PART

2

PART

3

taBle of contents



part 1

health netinsurance plans

FIT YOUR BUDGET, fit your life



3

Easy x 7 – the advantages o a Health Netinsurance plan

Easy to choose the health insurance plan that ts your budget and yourli e with a choice between a PPO and an HSA-compatible PPO option.1

Easy to fnd a doctor in your neighborhood rom the thousands o doctors and hospitals that are part o our statewide networks.

Easy to get care. All Health Net health insurance plans cover essentialpreventive care, emergency services and hospitalization.

Easy to use. Online tools plus people to talk with on the phone add upto a health insurance plan that’s actually easy to use.

Easy to a ord.Among the Health Net options that leave some change

in your pocket are our plans that work with Health Savings Accounts ortax-saving opportunities. Plus, our amily plan rates are based on the age o the younger spouse to save you a little bit more.

Easy to pay. Use your credit card. Set up an automatic bank dra t.Send us a check. When it comes to paying premiums, the choice is yours.

Easy to stay healthy and get well with no-cost extras like coaching,interactive guides and education that help you work with your doctorand make in ormed choices.

✓

✓

✓

✓

✓

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1 IFP PPO insurance plans, Policy Form # P30601 (CA 1/11), are underwritten by Health Net Li e Insurance Company.Health Net Li e Insurance Company is a subsidiary o Health Net, Inc.



4

Help ul de nitionsIn this guide, you’ll see words used that are speci c to

health care. We’ve de ned them here to make everythingast to read and easy to understand.

CoinsuranceThe percentage o covered expenses you pay or coveredservices, usually a ter you meet your deductible. Theseamounts vary by health plan.

Copayment (or copay)The xed-dollar ee that a Covered Person is required topay or covered services when the services are received inaddition to any applicable coinsurance and/or deductiblepayments. The copayment is due and payable to theprovider o care at the time the service is received.

DeductibleThe set amount a covered person or amily unit payseach calendar year or speci ed covered expenses be oreHealth Net pays any bene ts or those covered expenses.

Out-o -pocket maximum

The maximum amount o copayments, coinsurance anddeductibles you must pay or covered services or eachcalendar year.

Participating or pre erred providersPhysicians, hospitals or other providers o health care

who have a written agreement with HNL to participatein the PPO network and have agreed to provide insureds

with health care at a contracted rate. The Covered Personmust pay any deductible(s), copayment or coinsurancerequired, but is not responsible or any amount charged

in excess o the contracted rate. Participating or pre erredproviders can be ound online at www.healthnet.com.

PPO (Pre erred provider organization) A health care provider arrangement whereby HNLcontracts with a group o physicians or other medicalcare providers who agree to urnish covered servicesand supplies.

Get Your Own Quote and Apply Onlinehttp://www.healthnetworkinsurance.com/ca-get-quote







6

App ica t-o y a s th p a o y co so p so o a po icy. If yo ha otha o fa i y b ho’ i thisp a , th y ca app y fo a i i i a po ic

si th sa o t app icatio fo .

PPO INSURANCE PlAN

ValueNet ng

This PPO insurance plan is a low premium priceplan or those who rarely get sick or go to the doctor.ValueNet ng provides the security o just-in-casecoverage plus the fexibility o having two doctoro ce visits or a $35 copayment per visit (annual$4,000 deductible waived or these visits). In-network adult and child preventive care covered in ull. Allother covered services have a 35% coinsurance a terdeductible. This applicant-only plan includes a$10 generic prescription drug bene t.

PPO (continued)

Get your own quote and apply online below http://www.healthnetworkinsurance.com/ca-get-quote





7

Health Net’s EZ Access plans work just like our PPO

plans: You choose whether to see a provider in ournetwork or go to an out-o -network licensed physicianor health care pro essional. When you go out-o -network, you usually pay more or the services youreceive. Either way, you don’t need a re erral rom yourdoctor to see a specialist or go to the hospital.

What’s di erent about HSA-compatible PPOs is thatthe deductible is higher but you spend less on monthly premiums. Things to know:

• The HSA-compatible insurance plan has a combinedmedical and pharmacy deductible. This means thatyou pay the ull cost o prescriptions and medicalcare (at our negotiated rates) until your annualdeductible has been met.

• The deductible for child and adult preventive carebene ts is waived (in-network only).

• The plan deductible is combined for in-network andout-o -network services.

Plus, you can open an HSA and use tax- ree dollars to pay or quali ed medical expenses.2 Other HSA advantages:

• You have complete control over your health caredollars and can use them when you like.

• Contributions (up to the IRS maximum) and withdrawals are tax- ree when used or quali edmedical or pharmacy expenses.

• HSA funds can be invested, and investment earnings arenon-taxable when used or quali ed medical expenses.

• Long-term savings, rollover features (no time limitor using the unds) and catch-up contribution or

insureds between the ages o 55 and 65.

hSA-COmPAtIblE PPOINSURANCE PlAN

Optimum Advantage HSA ng

With a calendar year deductible amount o $4,500,this high-deductible PPO insurance plan works well orpeople who don’t go to the doctor o ten but who wantprotection against the unexpected.

EZ Access HSA: a high deductible PPOinsurance plan with tax-saving opportunities

With an Optimum Advantage HSA insurance plan,there are no surprises or hidden costs, and no complicatedcopayment/coinsurance structure to gure out. A ter youmeet your calendar-year deductible, in-network bene tsare paid at 100%. Plus, you have immediate coverage orchild and adult preventive care services.

Once you’re enrolled in this plan, you may open anHSA at any bank or nancial institution that o ersthem. To make it easy, Health Net has partnered withBank o America to o er our insureds an HSA that’s

easy to administer, quick to set up (within 15 calendardays), and comes with a convenient Bank o AmericaVISA debit card or account access.

IS An HSA-COmPATIBle PPORIGHT FOR YOU?

Yes, if you want:

• F o of choic , o f a s q i

• Co t o o ho ch yo sp – Yocosts a o h yo s o t o

• B oa t o acc ss th o ho tCa ifo ia. P s, h t a i , yo ’ ha

acc ss to o tha 4,700 hospita s a490,000 p o i s a ai ab atio ith o h a a a t ith Fi st H a th,® a atio a PPO t o .

• Co i c – o c ai fo s toh yo s t o s ic s.

• Tax-sa i a a ta s of a h a th sa i sacco t – a s a t ay to sa , sp ai st yo h a th ca o a s.2

2Federal tax in ormation only. State taxes may apply. Quali ed medical expenses include plan deductibles and copayments,as well as services such as vision, dental and prescription drugs. A full list of quali ed medical expenses is includedpublication 502 – Medical and Dental Expenses, which you can nd at www.irs.gov. Enter “502” in the search eld.

The HSA component o the program is o ered by Bank o America, N.A., as trustee o the HSA. Health Net is not a liated with Bank o America, N.A.



8

Dental and Vision A Health Net “PPO Plus” plan3 is a Health Net PPO

insurance plan with Health Net dental and visioncoverage included. It’s a great way to round out yourhealth coverage while enjoying the convenience o one-stop shopping.

DENtAl COvERAgE bENE I tS

• Choose your own dental providers.

Budget your care – Find out your costs up ront with our convenient ee schedule.

Save – The $50 deductible is waived or diagnosticand preventive services.

vISION COvERAgE bENE ItS

• Single, bifocal, trifocal and lenticular lenses coveredat 100% in-network a ter copayment.

Freedom to take your prescription to any vision PPOprovider.

• No or low copayments for vision exams and lenses,and allowances or other services.

• Large network of independent providers, includingoptical retailers LensCra ters, Pearle Vision, SearsOptical, JCPenney Optical and Target Optical.

• Secondary purchase plan – unlimited discounts up to40% on materials and services once initial bene t hasbeen used.

See pages 13–16 o this booklet or beneft details about these plans.

3Dental and vision bene ts are underwritten by Health Net Li e Insurance Company. Dental bene ts are administered by DentalBene t Administrative Services. Vision bene ts are administered by EyeMed Vision Care, LLC. Dental Bene t AdministrativeServices and EyeMed Vision Care, LLC are not a liated with Health Net Li e Insurance Company. For additional in ormationon dental and vision coverage provided under the Plus option, see the Dental and Vision Summary o Bene ts.



9

Individual Term Li e Insurance plansFor added peace o mind, you can purchase IndividualTerm Li e Insurance rom Health Net Li e InsuranceCompany.4 You can purchase a policy or yoursel , oryour spouse and/or or a dependent.

• You have a choice of ve coverage amounts forpolicies that cover you or your spouse:

– $10,000

– $20,000

– $30,000

– $40,000– $50,000

• $10,000 policies are available or children aged 1–17.

4Individual Term Li e Insurance is underwritten by Health Net Li e Insurance Company. Since you apply orhealth insurance with Health Net, there is no additionalin ormation required to review your eligibility or IndividualTerm Li e Insurance. Coverage will not become e ectiveuntil approved in writing by Health Net Li e InsuranceCompany.

The monthly premium is based on the age o theperson covered by the li e insurance policy.

There are a ew things to know about our li einsurance plans:

I you wish to purchase li e insurance, you mustpurchase a minimum $10,000 coverage. Themaximum li e insurance bene t is $50,000.

Not available with modi ed issue PPO plans,HIPAA Guaranteed Issue and Quick NetSelect plans.

Rates are subject to change.

A $10,000 $20,000 $30,000 $40,000 $50,000

1–17 $1.00 n/a n/a n/a n/a

18–29 $1.90 $3.80 $5.70 $7.60 $9.50

30–39 $2.40 $4.80 $7.20 $9.60 $12.00

40–49 $5.00 $10.00 $15.00 $20.00 $25.00

50–59 $13.70 $27.40 $41.10 $54.80 $68.50

60–64 $20.00 $40.00 $60.00 $80.00 $100.00

supplemental life insurance monthly rates



10

Bene ts at-a-glancethis Chart is designed to give you a quiCk Comparison o health net insuranCe plans.

inCluded is a summary o in-network bene its only and, there ore, is not intended orenrollment purposes. or bene it details, please see the summary o bene its on theollowing pages.

op i u ad an a e sa n a uene n(applicant only)

li etime maXimum Unlimited Unlimited

Calendar year deduCtible $4,500 single / $9,000 family $4,000

Calendar year out-o -poCketmaXimum

$4,500 single / $9,000 family $3,500

doCtor visit No charge after deductible is met $35 (deductible aived for rst 2 visits)1

X-ray and lab No charge after deductible is met 35%

maternity Care Not covered Not covered

preventive Care (adult and child) Covered in full (deductible aived) Covered in full (deductible aived)

emergenCy health Coverage No charge after deductible is met 35%

outpatient surgery (hospital or outpatient surgery center)

No charge after deductible is met 35%

outpatient aCility serviCes No charge after deductible is met 35%

hospitalization serviCes No charge after deductible is met 35%

outpatientpresCription drugs

No charge after deductible is met $10 Level I (generic)

See page 24 or ootnotes.



op i u ad an a e sa n

In-neTwOrk OuT-OF-neTwOrkli etime maXimum Unlimited

Calendar year deduCtiblesAll bene ts including pharmacy are subject to the deductible except preventivecare. Health Net ill begin to pay covered services in a family plan for eachindividual in the family once he or she satis es the individual deductible. Theremaining family members must continue to pay a deductible until they eitherindividually meet the individual deductible or until the amount paid by thefamily reaches the family deductible.

$4,500 single / $9,000 family

Calendar year out-o -poCket maXimum

Payments for services not covered by this plan ill not apply to

this calendar year out-of-pocket maximum.

$4,500 single / $9,000 family

(includes deductible)

$14,500 single / $29,000 family

(includes deductible)

pro essional serviCes Visit to physician (including specialist consultations) Covered in full after

deductible is met

50%

Prenatal and postnatal of ce visits Not covered

X-ray and laboratory procedures2 Covered in full after deductible is met

50%

preventive Care serviCes (adult and child) Routine preventive care services and immunizations3

Covered in full (deductible aived)

Not covered

emergenCy health Coverage Emergency room (professional and facility charge)

Covered in full after deductible is met

Urgent care center (facility charges) Covered in full after deductible is met

Ambulance Covered in full after deductible is met

outpatient serviCes 2 Outpatient surgery (hospital or outpatient surgery center charges only. Out-of-net ork maximum allo able charges are $600 per day.)


50%

Outpatient facility services2 (Out-of-net ork maximum allo able charges are $600 per day.)


50%

hospitalization serviCes 2 Inpatient, semiprivate hospital room or intensive care unit ith ancillary services (unlimited, except for non-severe mental health and substance abuse treatment. Out-of-net ork maximum allo able charges are $600 per day.)


50%

Maternity care in a hospital or skilled nursing facility Not covered

Surgeon or assistant surgeon and anesthetic service (inpatient hospital setting)


50%

other serviCes Rehabilitative therapy (includes physical, speech, occupational, respiratory and cardiac therapy)

Covered in full after deductible is met (20-visit maximum per

calendar year)

Not covered

Chiropractic care/acupuncture Covered in full after deductible is met (12-visit maximum per calendar year / $20 maximum payable per visit)

Not covered

Mental health for non-severe conditions2,4 Covered in full after deductible ismet (inpatient and outpatient)

50% (inpatient) / Not covered (outpatient)

Diabetic equipment 20% Not covered

Durable medical equipment (including foot orthotics) 50% ($2,000 maximum payableper calendar year)

Not covered

outpatient presCription drugs 5 Filled at participating pharmacy (up to a 30-day supply); not covered at non-participating pharmacies. Prescription drugs lled through mail order (up to a 90-day supply).


Not covered

11

Summary o bene ts –Optimum Advantage HSA ng Underwritten by Health Net Life Insurance Company this matriX is intended to be used to help you Compare Coverage bene its and is a

summary only. the poliCy should be Consulted or a detailed desCription o Coveragebene its and limitations. in Case o Con liCt, the poliCy Controls. bene its are subJeCtto deduCtible unless noted.




12

Summary o bene ts –ValueNet ng Underwritten by Health Net Life Insurance Company this matriX is intended to be used to help you Compare Coverage bene its and is a

summary only. the poliCy should be Consulted or a detailed desCription o Coveragebene its and limitations. in Case o Con liCt, the poliCy Controls. bene its are subJeCtto deduCtible unless noted.

a uene n (applicant only)

In-neTwOrk OuT-OF-neTwOrkli etime maXimum Unlimited

Calendar year deduCtibles(Not included in calendar year out-of-pocket maximum)

$4,000

Calendar year out-o -poCket maXimum Does not include calendar year deductible. Payments for services not coveredby this plan ill not apply to this calendar year out-of-pocket maximum.

$3,500

$7,000

pro essional serviCes Visit to physician (including specialist consultations) $35 (deductible aived

for rst 2 visits)1

50%

X-ray and laboratory procedures2 35% 50%

preventive Care serviCes (adult and child) Routine preventive care services and immunizations3

Covered in full (deductible aived)

Not covered

emergenCy health Coverage Emergency room (professional and facility charge)

35%

Urgent care center (facility charges) 35%

Ambulance 35%

outpatient serviCes 2 Outpatient surgery (hospital or outpatient surgery center charges only. Out-of-net ork maximum allo able charges are $600 per day.)

35%

50%

Outpatient facility services2 35% 50%

hospitalization serviCes 2 Inpatient, semiprivate hospital room or intensive care unit ith ancillary services (unlimited, except for non-severe mental health and substance abuse treatment. Out-of-net ork maximum allo able charges are $600 per day.)

35%

50%

Maternity care in a hospital or skilled nursing facility Not covered

Surgeon or assistant surgeon and anesthetic service (inpatient hospital setting)

35% 50%

other serviCes Outpatient rehabilitative therapy (includes physical, speech, occupational,respiratory and cardiac therapy)

35%

50%

Chiropractic care/acupuncture Not covered

Mental health for non-severe conditions2 35% 50%

Diabetic equipment 35% Not covered

Durable medical equipment ($2,000 maximum payable per calendar year)(including foot orthotics)

35% Not covered

outpatient presCription drugs 5,8

(medical deductible aived)Filled at participating pharmacy (up to a 30-day supply); not covered at non-participating pharmacies. Prescription drugs lled through participating mail order (up to a 90-day supply) require twice the level o copayment.

$10 Level I (generic)

Not covered




13

Summary o bene ts –Dental with PPO Plus coverage

the ollowing is intended as a summary only. the poliCy should be Consulted or a

detailed desCription o Coverage bene its and limitations.


ppo p us p ans: den aCalendar year maXimum $1,000

annual deduCtible ( aived for diagnostic and preventive services) $50

maxi A o ab F

diagnostiC and preventiveDiagnostic – periodic oral examination (up to 2x per year) $13

Diagnostic – limited oral examination, problem-focused $17

Intraoral radiographs – complete series, including bite ings $40

Dental prophylaxis – adult $32

Dental prophylaxis – children to age 14 $25

Sealant (per permanent molar tooth) $4

restorative – amalgam (permanent lling)One surface, permanent (amalgam) $22

T o surface, permanent (amalgam) $28

Cro n (resin/porcelain) $127 resin / $248 porcelain9

endodontiCs – root Canal (excluding nal restorations)Anterior $121 10

Molar $193 10

oral surgery (extractions) Single tooth, erupted $33

Removal of impacted tooth (completely bony) $66

periodontiCsPeriodontal scaling and root planing – 4 or more teeth per quadrant $23

prosthodontiCsProsthetics/prosthodontics – Denture (complete upper or lo er) $264 each

orthodontiCsChildren (through age 19) Not covered

Adult Not covered

Dental and vision bene ts are underwritten by Health Net Li e Insurance Company. Dental bene ts are administered by DentalBene t Administrative Services. Vision bene ts are administered by EyeMed Vision Care, LLC. Dental Bene t AdministrativeServices and EyeMed Vision Care, LLC are not a liated with Health Net Li e Insurance Company. For additional in ormation

on dental and vision coverage provided under the Plus option, see the Dental and Vision Summary o Bene ts.



14

Schedule o bene ts –Dental with PPO Plus coveragethis matriX is intended as a summary only. the poliCy should be Consulted or adetailed desCription o Coverage bene its and limitations.

d c cD0120 Periodic oral examination $13D0140 Limited oral evaluation, problem focused $17D0150 Comprehensive oral examination $17D0210 Intraoral – complete series including $40

bite ings (FMX)D0220 Intraoral – periapical, rst lm $10D0230 Intraoral – periapical, each additional lm $7D0240 Intraoral – occlusal lm $11D0250 Extraoral – rst lm $13D0260 Extraoral – each additional lm $10D0270 Bite ing – single lm $10D0272 Bite ings – t o lms $15D0274 Bite ings – four lms $21D0330 Panoramic lm $31

p cD1110 Dental prophylaxis – adult $32D1120 Dental prophylaxis – children to age 14 $25D1203 Topical application of uoride $17

(excluding prophylaxis – child) D1351 Sealant, per tooth $4D1510 Space maintainer – xed, unilateral $61D1515 Space maintainer – xed, bilateral $61D1520 Space maintainer – removable, unilateral $72D1525 Space maintainer – removable, bilateral $72

r cD2140 Amalgam – one surface, primary $19D2150 Amalgam – t o surfaces, primary $24D2160 Amalgam – three surfaces, primary $29D2161 Amalgam – four or more surfaces, primary $35D2140 Amalgam – one surface, permanent $22D2150 Amalgam – t o surfaces, permanent $28D2160 Amalgam – three surfaces, permanent $33D2161 Amalgam – four or more surfaces, permanent $39D2330 Resin – one surface, anterior $19D2331 Resin – t o surfaces, anterior $24D2332 Resin – three surfaces, anterior $29D2335 Resin – four or more surfaces $35

or involving incisal angle, anterior

D2390 Resin-based composite cro n – $31 anterior, (primary teeth)

D2510 Inlay metallic, one surface1 $66

D2520 Inlay metallic, t o surfaces1 $72

D2530 Inlay metallic, three or more surfaces1 $83

D2543 Onlay – metallic – three surfaces1 $110

D2544 Onlay – metallic – four or more surfaces1 $110

D2710 Cro n – resin-based composite (indirect)1 $127

D2720 Cro n resin ith high noble metal1 $154

D2721 Cro n resin ith predominantly base metal1 $154

co ered enef s axi ua o a e ee co ered enef s axi ua o a e eer c (c )

D2722 Cro n resin ith noble metal1 $154

D2740 Cro n porcelain/ceramic substrate 1 $248

D2750 Cro n porcelain fused to high noble metal1 $248

D2751 Cro n porcelain fused to $248 predominantly base metal1

D2752 Cro n porcelain fused to noble metal1 $248

D2790 Cro n full cast high noble metal1 $154

D2791 Cro n full cast predominantly base metal1 $154

D2792 Cro n full cast noble metal1 $154

D2794 Cro n – titanium $154D2910 Recement inlay, onlay or partial coverage $11

restorationD2915 Recement cast or prefabricated post and core $11D2920 Recement cro n $11D2930 Prefabricated stainless steel cro n, $31

primary toothD2931 Prefabricated stainless steel cro n, $31

permanent toothD2950 Core buildup, including any pins1 $22

D2952 Cast post and core in addition to cro n1 $28

D2954 Prefabricated post and core $28 in addition to cro n1

e c cD3110 Pulp cap – direct, excluding nal restoration $10D3120 Pulp cap – indirect, excluding nal restoration $17

D3220 Therapeutic pulpotomy, excluding nal $13 restoration – removal of pulp coronal to the dentinoenamel junction and application of medicament, primary teeth only

D3310 Root canal anterior, excluding nal $121 restoration2

D3320 Root canal bicuspid, excluding nal $143 restoration2

D3330 Root canal molar, excluding nal $193 restoration2

d3346 Retreatment of previous $121root canal therapy – anterior2

d3347 Retreatment of previous $143root canal therapy – bicuspid2

d3348 Retreatment of previous $193

root canal therapy – molar2 D3410 Apicoectomy/periradicular surgery, anterior 2 $66

D3421 Apicoectomy/periradicular surgery, bicuspid $88 ( rst root) 2

D3425 Apicoectomy/periradicular surgery, molar $88 ( rst root) 2

D3426 Apicoectomy/periradicular surgery $28 (each additional root) 2

D3430 Retrograde lling, per root2 $17



15

p c cD4210 Gingivectomy or gingivoplasty, per quadrant2 $99

D4211 Gingivectomy or gingivoplasty – one to three $28 contiguous teeth or bounded teeth spaces – per quadrant

D4260 Osseous surgery (including fap entry and $176closure) – four or more contiguous teeth or bounded teeth spaces, per quadrant2

D4261 Osseous surgery (including fap entry and $44closure) – one to three contiguous teeth or bounded teeth spaces – per quadrant2

D4341 Periodontal scaling and root planing – $23 four or more teeth – per quadrant2

D4342 Periodontal scaling and root planning – $11 one to three teeth, per quadrant2

p c –

D5110 Complete upper denture1

$264D5120 Complete lo er denture1 $264

D5130 Immediate upper denture1 $264

D5140 Immediate lo er denture1 $264

D5211 Upper partial – resin base1 $132

D5212 Lo er partial – resin base1 $132

D5213 Upper partial – cast metal base $264 ith resin saddles1

D5214 Lo er partial – case metal base ith $264 resin saddles1

D5281 Removable unilateral partial denture – $88 one piece cast metal1

D5410 Adjust complete denture, upper $11D5411 Adjust complete denture, lo er $11

D5421 Adjust partial denture, upper $11D5422 Adjust partial denture, lo er $11D5510 Repair broken complete denture base $22D5520 Replace missing or broken teeth $8

complete denture, each toothD5610 Repair resin saddle or base $22D5640 Replace tooth on denture, no other repair, $8

each toothD5650 Add tooth to partial denture to replace $9

extracted tooth, not involving claspsD5660 Add clasp or rest to existing partial denture $9D5710 Rebase complete upper denture $28D5711 Rebase complete lo er denture $28D5720 Rebase partial upper denture $28

D5721 Rebase partial lo er denture $28D5730 Reline upper complete denture, chairside $28D5731 Reline lo er complete denture, chairside $28D5740 Reline upper partial denture, chairside $28D5741 Reline lo er partial denture, chairside $28D5750 Reline upper complete denture, laboratory $61D5751 Reline lo er complete denture, laboratory $61D5760 Reline upper partial denture, laboratory $61D5761 Reline lo er partial denture, laboratory $61D5820 Interim partial denture, anterior stayplate $50

(upper) 1

D5821 Interim partial denture, anterior stayplate $50 (lower) 1

p c – fxD6210 Pontic – cast high noble metal1 $77

D6211 Pontic – cast predominantly base metal1 $77

D6212 Pontic – cast noble metal1 $77

D6214 Pontic – titanium $77D6240 Pontic, porcelain fused to high noble metal1 $138

D6241 Pontic, porcelain fused to predominantly $138 base metal1

D6242 Pontic, porcelain fused to noble metal1 $138

D6250 Pontic, resin ith high noble metal1 $94

D6251 Pontic, resin ith predominantly base metal1 $94

D6252 Pontic, resin ith noble metal1 $94

D6930 Recement xed partial(bridge) $17

o D7111 Extraction, coronal remnants – $22

deciduous tooth2

D7140 Extraction, erupted tooth or exposed root $22 (elevation and/or orceps removal) 2

D7140 Extraction, erupted tooth or exposed root $22 (elevation and/or orceps removal) , each additional tooth hen performed on the same visit as the rst extraction2

D7210 Surgical removal of erupted tooth2 $33

D7220 Removal of impacted tooth, soft tissue2 $44

D7230 Removal of impacted tooth, partially bony2 $55

D7240 Removal of impacted tooth, $66 completely bony2

D7241 Removal of impacted tooth, $66 completely bony, complications2

D7310 Alveoloplasty in conjunction ith $22

extractions, per quadrant2D7311 Alveoloplasty in conjunction ith extractions – $11

one to three teeth or tooth spaces, per quadrantD7320 Alveoloplasty not in conjunction $44

ith extractions, per quadrant2

D7321 Alveoloplasty not in conjunction ith $22 extractions – one to three teeth or tooth spaces, per quadrant2

D7471 Removal of lateral exostosis $61 (maxilla or mandible) , per site2

D7970 Excision of hyperplastic tissue, per arch2 $55

a j c cD9220 General anesthesia, rst 30 minutes $28D9310 Specialist consultation $20 D9430 Of ce visit, regular hours, no other service $20D9440 Of ce visit, after hours, no other service $20

1Subject to six-month aiting period2Subject to three-month aiting period

co ered enef s axi ua o a e ee

co ered enef s axi ua o a e ee



16

Summary o bene ts –Vision with PPO Plus coverage

the ollowing is intended as a summary only. the poliCy should be Consulted or a

detailed desCription o Coverage bene its and limitations.

Dental and vision bene ts are underwritten by Health Net Li e Insurance Company. Dental bene ts are administered by DentalBene t Administrative Services. Vision bene ts are administered by EyeMed Vision Care, LLC. Dental Bene t AdministrativeServices and EyeMed Vision Care, LLC are not a liated with Health Net Li e Insurance Company. For additional in ormationon dental and vision coverage provided under the Plus option, see the Dental and Vision Summary o Bene ts.

ppo p us p ans: isionI -n t o Yo Pay O t-of-n t o Yo Pay

eXam with dilation as neCessary Once every 12 months $10 copayment All charges over $45

eXam options ( t and follo -up)Standard contact lenses Up to $55 Not covered

Premium contact lenses You receive a 10% discount off retail price Not covered

ramesOnce every 24 months $85 allo ance Not applicable

Any available frame at provider location $0 copayment, plus 80% of balance over allo ance All charges over $45

standard plastiC lensesSingle vision $25 copayment All charges over $43

Bifocal $25 copayment All charges over $58

Trifocal $25 copayment All charges over $70

Lenticular $25 copayment All charges over $125

Standard progressive lens $90 copayment All charges over $58

Premium progressive lens $90 copayment, plus 80% of charge less $120allo ance

All charges over $58

lens optionsUV treatment You receive a 20% discount off retail price Not covered

Tint (solid and gradient) $0 copayment Not covered

Standard plastic scratch – Coating You receive a 20% discount off retail price Not covered

Standard polycarbonate – Adults You receive a 20% discount off retail price Not covered

Standard polycarbonate – Children under age 19 You receive a 20% discount off retail price Not covered

Standard anti-re ective coating You receive a 20% discount off retail price Not covered

Other add-ons You receive a 20% discount off retail price Not covered

ContaCt lensesOnce every 24 months in lieu of eyeglass lenses(Contact lens allo ance includes materials only.)

$120 allo ance Not applicable

Conventional $25 copayment, plus 85% of charge over allo ance

All charges over $105

Disposable $25 copayment, plus balance over allo ance All charges over $105

Medically necessary (requires pre-authorization) $25 copayment All charges over $250

laser vision CorreCtionLASIK or PRK from U.S. Laser Net ork You receive 15% discount off retail price or 5%

discount off promotional priceNot covered

additional pairs bene it You receive a 40% discount off complete (framesand lenses) pair eyeglass purchases and a 15%discount off conventional contact lenses oncethe bene t has been used.

Not covered



NO-COST eXtras

part 2



18

Decision Power:® Health in BalanceInformation, resources and support for every person, every stage of health

When you choose Health Net, you get more than health

care coverage. You get Decision Power.5 Decision Power brings together under one roo thein ormation, resources and personal support that t you,your health and your li e. Whether you’re ocused onstaying t, dealing with back pain or acing a seriousdiagnosis, we’re here to help you work with your doctorand make in ormed decisions. Here’s how it works:

StAyINg hEAl thy IS jUSt AS ImPORtANt AS gEtt INg wEll .

Making the most o your health is what Decision Poweris all about. We’re ocused on your whole health, not justone concern or disease. So we work with you to identi y potential health risks, and help prevent minor concerns

rom becoming big problems. And we’re here should youace serious medical concerns.

yOUR hEAlth, yOUR tImE. yOUR ChOICE.

Whether you …

• have a question

• want help with a speci c health goal

• need treatment but want to understand all your options

• are living with illness

… you choose how and when to use the in ormation,resources and support available. You can use DecisionPower online or by calling a Health Coach. Try multipleresources at once, or one at a time. 24 hours a day, sevendays a week, Decision Power is here or you.

Log on to www.healthnet.com:

Take the health risk questionnaire (HRQ) – With itsinstant results and interactive features, the HRQ is yourgateway to recommendations and resources based onyour unique health pro le.

Try a step-by-step plan or losing weight, stoppingsmoking or boosting nutrition. You can start with our

online coaching and sel -help tools. Phone coachingsupport is included so making lasting, healthy changesis easier.

Set up a Personal Health Record to track your healthprogress and have a complete medical snapshot wheneveryou need it.

Find support or any kind o mental health concern suchas depression, excessive alcohol use, eating disorders, etc.

Be in ormed – Access in ormation resources, suchas Healthwise Knowledgebase, an online health

encyclopedia; HEAR Audio Library, which containsin ormation on 355 health topics; and Health Crossroads Web Modules, which explains the pros and cons o various treatments.

Know your numbers – with our health trackers(cholesterol, diet, tness), treatment cost estimator andhospital comparison reports.

5Decision Power is not part o Health Net’s commercial medical bene t plans. Also, it is not a liated with Health Net’s providernetwork and it may be revised or withdrawn without notice. Decision Power services, including Health Coaches, are additionalresources that Health Net makes available to enrollees o Health Net Li e Insurance Company.



19

SelF-ServICe AT www.HeAlTHne .CO mO c yo o ith H a th n t, yo ’ ha a o-to o i so c fo yo h a th p aa asy ay to t o of yo to- o ist o fast:

mY HeAlTH neT: AT YOur FIngerTIPS Yo ’ th i fo atio yo s o ost i yo p so a “my H a th n t”that ta s yo h yo a t to o i j st o o s c ic .

PrOvIder SeArCH mAde SImPleFi a sp ci c octo , ocat th a st hospita , o s a ch fo th s ic s yoo s a ch i . P s, yo ca t is a aps that sho th p cis ocatio of tho hospita .

QuICk lInkS: ClICk And gOO Id ca s. Fi a a by pha acy. us d cisio Po . Yo ca o a this a o si th Q ic li s f at o th

ft of y pa .

Talk to a Health Coach to get:

1-to-1 consultations and a single point o contact or any and every health question, goal or situation. You can talk

to the same Health Coach every time you call, and aboutany health goal or challenge.

Steps to avoid cardio-metabolic risk – the combinationo three or more o the six risk actors (e.g., waist size,blood pressure, HDL cholesterol level) that predictdiabetes, heart disease and colon, uterine and prostatecancers.

24-hour answers to health questions or concerns. Alwayscall 9-1-1 or go straight to the emergency room in a li e-threatening situation.

Pointers or setting achievable health goals; guidance onevaluating treatment options.

Guidance and support or living with an ongoing illnesssuch as asthma, diabetes, heart disease, etc.

Specialized consultation rom nurse case managers tohelp both patients and amily members deal with thecomplexity o end-stage illnesses.

Decision Po er – Use it henever and as often as you lik

Because hen it comes to ythere’s more than one right ans er.

DOCtOR-PAtIENtCONNECtION.

Doctors know medicine. You know your body. WithDecision Power, it’s easy to learn what questions to ask,how to explain your pre erences and to get the supportyou need rom your doctor. The more you know, theeasier it is to navigate complicated health choices andmake the ones that are right or you.

TW ORK INSUR ANCE

www.H E ALTHNE TW ORK INSUR ANCE .COM







































part 3

applyingfor health net coverage



21

How to apply –3 easy steps to a better decision

Applying or Health Net medical, dental, vision or li einsurance coverage is as easy as, well, 1-2-3:

Apply online or through your authorized broker.

Online: www.healthnetworkinsurance.com

Note that the application MUST be completed,signed and dated by the applicant even i

you’re working with a broker. Neither thebroker nor any other person may complete theStatement o Health or sign the applicationand agreement on behal o the applicant(s).

A ter your application is complete:

• Include payment for the applicable premiumamount by check, automatic bank dra t orcredit card.

• Mail the completed application and check (within30 days o the date you signed the application)to your agent or directly to Health Net:

Health NetIndividual & Family PlansPost O ce Box 1150Rancho Cordova, CA 95741-1150

Look or your ID card and plan materialsin the mail.

Enjoy the benefts o membership –big networks, personal service and ground-breaking wellness resources.

I you have any questions, please callyour authorized broker or Health Net at1-800-909-3447, option 2.

1

2

3

Want to know more be ore you choose Health Net? We would too i we were you. So come on over to www.healthnetworkinsurance.comand take a look

• Compare plan costs – Quickly estimate your amily’sannual health care costs or di erent plan options.

• Search our doctor network to see i your

current doctor is included, or nd one close tohome or work.

• View our Drug List to see what brand-name andgeneric medications we cover, learn about ourpharmacy services, and nd answers to commonly asked questions.

I you have speci c questions, please let us know. A member o our riendly, knowledgeable customerservice sta is available to assist you Monday throughFriday. Just email: dennisa@@ healthnetworkinsurance.com

Take a test drive

Easy. Affordable.

Health

around. You can:







22

Important things to know about your medical coverageWho is eligible? To be eligible or Health Net Individual & Family PPO, you must: be under the age o 65, not be eligible

or Medicare, reside continuously in our servicearea, and meet our application and underwritingrequirements or coverage.

In addition, your spouse or domestic partner, i underage 65, and all your dependent children under 26 yearso age are also eligible.

Domestic Partner is de ned as two adults who havechosen to share one another’s lives in an intimate andcommitted relationship o mutual caring.

A Domestic Partner is a person eligible or coverage providedthat the partnership with the Applicant meets all domesticpartnership requirements under Cali ornia law or anotherrecognized state or local agency. The Domestic Partner and Applicant must meet the ollowing requirements:

• Both persons have a common residence.

• Neither person is married to someone else or is amember o another domestic partnership that has not

been terminated, dissolved, or judged a nullity.• The two persons are not related by blood in a way that

would prevent them rom being married in Cali ornia.

• Both persons are at least 18 years old.

• Both persons are members of the same sex, oropposite sex couples i one or both persons is overage 62 and is eligible or Social Security bene ts.

• Both persons are capable of consenting to thedomestic partnership.

• Both le a Declaration of Domestic Partnership withthe Secretary o State or an equivalent document romanother recognized state or local agency, or both arepersons o the same sex who have validly ormed a legalunion other than marriage in a jurisdiction outside o Cali ornia which is substantially equivalent to a DomesticPartnership as de ned under Cali ornia law.

What is Special Open Enrollment or children under 19 years o age? There is an Open Enrollment period or children under

19. Please talk to your broker or contact Health Net

or more in ormation.

Am I eligible or guaranteed issue coverage, without the need or medical underwriting? The ederal Health Insurance Portability and

Accountability Act (HIPAA) makes it easier or peoplecovered under existing group health plans to maintaincoverage regardless o pre-existing conditions whenthey change jobs or are unemployed or brie periodso time. Cali ornia law provides similar and additionalprotections. Applicants who meet the ollowingrequirements are eligible to enroll in a guaranteed issue

individual health plan rom any health plan that o ersindividual coverage, including Health Net’s GuaranteedPPO plans, without medical underwriting. A healthplan cannot reject your application or guaranteed issueindividual health coverage i you meet the ollowingrequirements, agree to pay the required premiums andlive or work in the plan’s service area.

To quali y or a HIPAA plan, you must meet theollowing requirements:

• Have completed a total of 18 months of coverage

without a signi cant break (excluding any employer-imposed waiting period).

• The most recent coverage must have been undera group health plan (COBRA and Cal-COBRAcoverage are considered group coverage).

• The applicant must not be eligible for coverage undeany group health plan, Medicare or Medicaid, andmust not have other health insurance coverage.

• The individual’s most recent coverage could not havebeen terminated due to raud or nonpayment o premiums.

• If COBRA or Cal-COBRA coverage was available, imust have been elected and such coverage must havebeen exhausted.



23

I you want to nd out i you quali y, contact us so that we can determine your eligibility and tell you about theavailable HIPAA plans. I you believe your rights underHIPAA have been violated, please contact the Cali orniaDepartment o Insurance at 1-800-927-HELP (4357)or TDD 1-800-482-4833 or visit their website athttps://interactive.web.insurance.ca.gov/contactCSD/ContactUs.jsp

How does the monthly billing work? Your premium must be received by Health Net by the rstday o the coverage month. I there are premium increases

a ter the enrollment e ective date, you will be noti ed atleast 30 days in advance. You can choose to pay monthly by check, automatic bank dra t (ABD) or credit card. A Simple Pay Option orm will need to be completedand submitted to Health Net to set up ABD or paymentby credit card. I there are changes to the Health NetIndividual & Family PPO Policy, including changes inbene ts, you will be noti ed at least 30 days in advance.

Are there any renewal provisions? Subject to the termination provisions discussed, coverage will remain in e ect or each month premiums arereceived and accepted by Health Net. You will be noti ed30 days in advance o any changes in ees, bene ts orcontract provisions.

Does Health Net coordinate benefts? There are no Coordination o Bene t provisions orindividual plans in the state o Cali ornia.

Does Health Net cover the cost o participation in clinical trials? Routine patient care costs for patients diagnosed withcancer who are accepted into phase I, II, III or IV clinical trials are covered when Medically Necessary,recommended by the Insured’s treating physician andauthorized by Health Net. The physician must determinethat participation has a meaning ul potential to bene t theInsured and the trial has therapeutic intent. For urtherin ormation, please re er to the PPO Policy.

What is the relationship o the involved parties? Physician groups, contracting physicians, hospitals andother health care providers are not agents or employees o Health Net Li e. Health Net Li e and each o its

employees are not the agents or employees o any physiciangroup, contract physician, hospital or other health careprovider. All o the parties are independent contractors andcontract with each other to provide you the covered servicesor supplies o your coverage option. Insureds are not liable

or any acts or omissions o Health Net Li e, their agentsor employees, or o physician groups, any physician orhospital, or any other person or organization with whichHealth Net Li e has arranged or will arrange to provide thecovered services and supplies o your plan.

What are Severe Mental Illness and Serious Emotional

Disturbances o a Child? Severe Mental Illness includes schizophrenia, schizoa ectivedisorder, bipolar disorder (manic-depressive illness),major depressive disorders, panic disorder, obsessive-compulsive disorders, pervasive developmental disorder(including Autistic Disorder, Rett’s Disorder, ChildhoodDisintegrative Disorder, Asperger’s Disorder and PervasiveDevelopmental Disorder not otherwise speci ed to include

Atypical Autism, in accordance with the most recentedition o the Diagnostic and Statistical Manual or MentalDisorders), autism, anorexia nervosa and bulimia nervosa.

Serious emotional disturbances o a child is when a childunder the age o 18 has one or more mental disordersidenti ed in the most recent edition o the Diagnosticand Statistical Manual o Mental Disorders, other thana primary substance abuse disorder or a developmentaldisorder, that result in behavior inappropriate to thechild’s age according to expected developmental norms.In addition, the child must meet one or more o the

ollowing: (a) as a result o the mental disorder thechild has substantial impairment in at least two o the

ollowing areas: sel -care, school unctioning, amily relationships or ability to unction in the community;and either (i) the child is at risk o removal rom homeor has already been removed rom the home, or (ii) themental disorder and impairments have been present ormore than six months or are likely to continue or morethan one year; (b) the child displays one o the ollowing:psychotic eatures, risk o suicide or risk o violence dueto a mental disorder; and/or (c) the child meets specialeducation eligibility requirements under Chapter 26.5(commencing with Section 7570) o Division 7 o Title

1 o the Government Code.



24

1Deductible waived or the rst 2 visits o pro essional services. Additional visits are covered with coinsurance a ter deductible.2Certain services require prior certi cation from Health Net. Without prior certi cation, the bene t is reduced by 50%. Refer to the Policy for details.3Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations o the Advisory Committee on

Immunization Practices (ACIP) that have been adopted by the Director o the Centers or Disease Control and Prevention (CDC); and comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents.4Treatment of non-severe mental disorders is limited to 20 outpatient visits and 30 inpatient days per calendar year. Refer to the applicable Policy for maximum allowableamounts.

5The recommended Drug List is a list o prescription drugs that are covered by this plan. Some drugs require prior authorization rom Health Net. For a copy o theRecommended Drug List, go to Health Net’s website. Re fer to the Policy for complete information on prescription drugs.

6Copayment does not apply once annual out-o -pocket maximum is met.7Copayment continues to apply a ter annual out-o -pocket maximum is met.8Prescription drug charges do not apply to your maximum out-o -pocket limit. Brand deductible per person, i applicable, is in addition to the medical deductible and must bepaid or prescription drug covered services be ore Health Net begins to pay.

9Subject to six-month waiting period. 10Subject to three-month waiting period.

Footnotes or pages 10–13



Health NetIndividual & Family PlansPost O fce Box 1150Rancho Cordova, Cali ornia 95741-1150

6023465 CA74806 (1/11)PPO insurance plans, Policy Form # P30601 (CA 1/11), are underwritten by Health Net Li e Insurance Company. Health NetLi e Insurance Company is a subsidiary o Health Net, Inc. Health Net, A Better Decision, and Decision Power are registeredservice marks o Health Net, Inc. All other identifed trademarks / service marks remain the property o their respective

companies. Dental Terminology© 2010 American Dental Association. All rights reserved.

www.healthnetworkinsurance.com





HEALTH NET PPOINSURANCE PLANS

Outline of Coverage and Exclusions and Limitations



Table o contents

Health Plans

Outline o coverage

Read your Policy care ully

Major medical expense coverage

Principal bene ts and coverages

Cost sharing

Certi cation (Prior authorization o services)

Exclusions and limitations

Pre-existing conditions

Renewability o this Policy

Premiums

Loss ratio

Dental and Vision PPO Plus Plans

Covered services and supplies, exclusions and limitations

Dental

Vision



Outline o coverageHealth Net Life Insurance Company Individual & Family Health Insurance Plans major medical expense coverage

Read YouR Pol icY caReful lY

This outline o coverage provides a brie description o the important eatures o your Health Net PPO Policy (Policy) This is not the insurance contract and only theactual Policy provisions will control The Policy itsel sets orth, in detail, the rights and obligations o bothyou and Health Net Li e Insurance Company It is,there ore, important that you read your Policy care ully!

MajoR Medical exPense coveRage

This category o coverage is designed to provide, topersons insured, bene ts or major hospital, medicaland surgical expenses incurred as a result o a coveredaccident or sickness Bene ts may be provided or daily hospital room and board, miscellaneous hospital services,surgical services, anesthesia services, in-hospital medicalservices, out o hospital care and prosthetic appliancessubject to any deductibles, copayment provisions orother limitations which may be set orth in the Policy

PRinciPal Benef i t s and coveRagesPlease re er to the list below or a summary o each plan’scovered services and supplies Also re er to the Policy you receive a ter you enroll in a plan The Policy o ersmore detailed in ormation on the bene ts and coverageincluded in your health insurance plan

• Inpatient hospital services

• Outpatient hospital services

• Ambulatory surgical center

• Skilled nursing facility

• Professional services

• Routine physical examinations

• Diagnostic imaging (including X-ray) and laboratory procedures

• Home health care agency services

• Outpatient infusion therapy

• Ambulance services – ground ambulancetransportation and air ambulance transportation

• Acupuncture

• Diabetes education

• Hospice care

• Radiation therapy, chemotherapy and renal dialysis treatment

• Bariatric (weight loss) surgery

• Prostheses

• Medically necessary corrective footwear

• Rental or purchase of durable medical equipment• Implanted lens which replaces the organic eye len

• Cardiac rehabilitation therapy

• Pulmonary rehabilitation therapy

• Allergy testing and treatment

• Self-injectable drugs

• Surgically implanted drugs

• Allergy serum – covered only when provided byparticipating provider

• Sterilizations for male and female

• Diabetic equipment

• Reconstructive surgery

• Dental injury

• Phenylketonuria (PKU)

• Care for conditions of pregnancy

• Organ, tissue and bone marrow transplants

• Clinical trials

• Chiropractic bene ts

• Mental health care and chemical dependency bene

2



cos t shaRing

Coverage is subject to deductible, coinsurances andcopayments Please consult the Policy or complete details

ceRt i f ica t ion (PRioR authoRization of seRvices)

Some services are subject to pre-certi cation. Pleaseconsult the complete list o services in the Policy

exclus ions and l iMita t ions

The ollowing is a list o services that are not generally covered For complete details on any plan’s exclusionsand limitations, please see the Policy or complete details

• Services or supplies that are not Medically Necessary.

• Any amounts in excess of the maximum amounts

speci ed in the Policy• Pregnancy or maternity services, except as speci ed in

the Policy

• Cosmetic surgery except as speci ed in the Policy.

• Contraceptive drugs and/or certain contraceptivedevices are covered as speci ed in the Policy Vaginalcontraceptive devices are only covered when aPhysician prescribes the device and per orms a ttingexamination as speci ed in the Policy

• Dental services except as speci ed in the Policy.

• Treatment and services for Temporomandibular (Jaw Joint Disorders (TMJ).

• Surgery and related services for the purposes ofcorrecting the malposition or improper development o the bones o the upper or lower jaw, except when suchprocedures are Medically Necessary

• Food or dietary, nutritional supplements, exceptor ormulas and special ood products to prevent

complications of Phenylketonuria (PKU).

• Vision care including certain eye surgeries to replaglasses, except as speci ed in the Policy

• Optometric services or eye exercises, except asspeci cally stated elsewhere in the Policy

• Eyeglasses or contact lenses, except as speci ed in the Policy

• Sex changes.

• Services to reverse voluntary surgically inducedin ertility

• Services or supplies that are intended to impregnat woman are not covered

• Certain genetic testing.

• Experimental or investigative services.

• Routine physical exams, except for preventive careservices (e g , physical exam or insurance, licensing,employment, school or camp ) Any physical, vision

or hearing exams which are not related to diagnosisor treatment o illness or injury, except as speci cally stated in the Policy

REPRODUCTIVE HEALTH SERVICES

Some hospitals and other providers donot provide one or more of the followingservices that may be covered under yourPolicy and that you or your family membermight need: family planning; contraceptiveservices, including emergency contraception;sterilization, including tubal ligation atthe time of labor and delivery; infertilitytreatments; or abortion. You should obtainmore information before you enroll. Callyour prospective doctor, medical group,independent practice association or clinic,or call Health Net Life’s Customer ContactCenter at 1-800-839-2172 to ensure that

you can obtain the health care services thatyou need.

3



• Immunizations or inoculations for adults or children,except as described in the “Medical Bene ts” section or

or oreign travel or occupational purposes

• Services not related to a covered illness or injury.

• Custodial or domiciliary care.

• Inpatient room and board charges incurred inconnection or an admission to a Hospital or otherInpatient treatment acility, primarily or diagnostictests which could have been per ormed sa ely on anoutpatient basis

• Inpatient room and board charges in connection witha Hospital stay primarily or environmental change,physical therapy or treatment o chronic pain

• Any services or supplies furnished by a non-eligibleinstitution, which is other than a legally operatedHospital or Medicare-approved Skilled NursingFacility, or which is primarily a place or the aged, anursing home or any similar institution, regardless o how designated

• Expenses in excess of a Hospital’s (or other inpatientacility’s) most common semi-private room rate

• Infertility services.

• Private duty nursing.

• Mental and nervous disorder and substance abusetreatment, except as speci ed in the Policy

• Hyperkinetic syndromes, learning disabilities,behavioral problems or mental retardation unlessdue to severe mental illness or serious emotionaldisturbances o a child

• Over-the-counter medical supplies and medications.

• Personal comfort items.

• Orthotics, unless custom made to t the CoveredPerson’s body and as speci ed in the Policy

• The Policy does cover certain Medically Necessarydiabetic equipment.

• Educational services or nutritional counseling, exceptas speci ed in the Policy

• Hearing aids.

• Obesity related services.

• Any services received by Medicare bene ts withopayment o additional premium

• Services received before your effective date of co

• Services received after coverage ends.

• Services for which no charge is made to the CoPerson in the absence o insurance coverage, exceptservices received at a charitable research Hospital which is not operated by a governmental agency

• Physician self-treatment.

• Services provided by immediate family members.

• Conditions caused by the Covered Person’scommission (or attempted commission) o a elony unless the condition was an injury resulting rom anact o domestic violence or an injury resulting rom amedical condition

• Conditions caused by release of nuclear energy, wgovernment unds are available

• Any services provided by, or for which paymentmade by, a local, state or ederal government agencyThis limitation does not apply to Medi-Cal, Medicaidor Medicare

• Services for conditions of pregnancy for a surrogparent are covered, but when compensation is obtainedor the surrogacy, we shall have a lien on such

compensation to recover its medical expense

• Any outpatient drugs, medications or other substandispensed or administered in any outpatient settingexcept as stated in the Policy

• Sexual dysfunction drugs.

• Rehabilitative services rendered in an outpatient fa

are not covered• Psychosocial speech delay (includes delayed langu

development)

• Mental retardation or dyslexia.

• Attention de cit disorders and associated behavior problems

4



• Developmental articulation and language disorders.

• However, some of the above conditions shall becovered as shown in the “Schedule of Bene ts” section,i Medically Necessary as described in the de nitionsof “Serious Emotional Disturbances of a Child” and/or “Severe Mental Illness,” and continuous functional

improvement in response to the treatment plan isdemonstrated by objective evidence

• Outpatient speech therapy, except as speci ed in the Policy

• Services and supplies obtained while in a foreigncountry with the exception o Emergency Care

• Home birth.

• Reimbursement for services for which the CoveredPerson is not legally obligated to pay the provider inthe absence o insurance coverage

• Physical exams for insurance, licensing, employment,school or camp Any physical, vision or hearing examsthat are not related to diagnosis or treatment o illnessor injury, except as speci cally stated in the Policy

• Amounts charged by out-of-network providers or covered medical services and treatment that

Health Net Li e determines to be in excess o thecovered expense

• Treatment of chronic alcoholism, drug addictionand other chemical dependency problems, includingdetoxi cation services, except as speci cally stated inthe Policy

• Any expenses related to the following items, whetherauthorized by a physician or not: (a) alteration o the Covered Person’s residence to accommodatethe Covered Person’s physical or medical condition,including the installation o elevators; (b) corrective

appliances, except prosthetics, casts and splints; (c)air puri ers, air conditioners and humidi ers; and (d)educational services or nutritional counseling, except asspeci cally provided in the Policy

• Disposable supplies for home use.

• Services performed by a person who lives in theCovered Person’s home or who is related to theCovered Person by blood or marriage

Some services require pre-certi cation from Health Nprior to receiving services Please re er to your Policy odetails on what services and procedures require pre-certi cation

Health Net Life does not require pre-certi cation fordialysis services or maternity care

PRe-exist ing condit ions

Services or supplies received for the treatment of a Pre-Existing Condition during the rst 6 consecutivemonths during which the Covered Person is covered(including any waiting period) Except that:

1 This exclusion shall not apply to a child newly bornto, or newly adopted by, an enrolled Policyholder orhis or her spouse or domestic partner, or to a childunder 19

2 This exclusion shall not apply to conditionso pregnancy

3 I a Covered Person becomes eligible or coverageunder this Policy within 63 days o the terminationo any Creditable Coverage, that Covered Person willbe given credit toward the 6-month waiting period ortime covered by the Creditable Coverage

RenewaBil i tY of th is Pol icY

Subject to the termination provisions discussed in thePolicy, coverage will remain in e ect or each monthpremiums are received and accepted by Health Net

PReMiuMs

We may adjust or change your premium I we changeyour premium amount, notice will be mailed to youat least 60 days prior to the premium change e ectivedate Premiums are automatically adjusted or changes inyour and your dependent spouse’s or registered domestic

partner’s ages Premiums may be adjusted when yourresidence address changes

loss Rat io

Health Net Li e’s 2009 ratio or the Individual & Family PPO insurance plans was 83 2 percent

5



6

Covered services andsupplies, exclusionsand limitationsDental and Vision PPO Plus coverage

The ollowing are selective listings only For acomprehensive listing see the Health Net PPO Policy

denta l

1. Type I: Preventive and diagnostic dental services

Coverage is provided or the ollowing preventive dentalservices and subject to the ollowing limitations:

a) Initial or periodic oral exams, limited to two per12-month period Initial exams will be limited to the

allowance or a periodic examb) Intraoral complete series X-rays, including 4 bitewings

and up to 14 periapical X-rays, or panoramic lm with 4 bitewings, either is limited to one per 36-monthperiod and no payment or any combination o lmsshall exceed the amount determined or a completeseries of X-rays.

c) Bitewing X-rays series (two or four lms), limited toone per 12-month period

d) If an intraoral complete or panoramic X-ray withbitewings has not been provided in a 36-monthperiod, then a panoramic lm without bitewings is abene t and is limited to one per 36-month period

e) Intraoral periapical X-rays, limited to four lmsper 6-month period when per ormed as a separateprocedure from a complete series of X-rays.

f) Intraoral occlusal X-rays, limited to two lms per

12-month period

g) Extraoral X-rays, limited to two lms per 12-moperiod

h) Bitewing X-rays are not covered within a 12-moperiod rom the date o an intraoral complete series X-rays.

i) Dental prophylaxis (cleaning and scaling), limitedto two per 12-month period

j) Topical fuoride treatment is limited to one per12-month period or Dependent children under age 16

k) Sealants are limited to one application to an unrespermanent rst or second molar tooth per 36-monthperiod for Dependent children under age 14.

l) Space maintainers for primary teeth (limited to

initial appliance only), including all adjustments andrecementation made within 6 months o installation,limited to dependent children under age 14.

m) Emergency oral exams

n) Limited oral evaluation, problem ocused

2. Type II: Basic dental services (Non-restorative)

Coverage is provided or the ollowing non-restorativebasic dental services and subject to the ollowing

limitations:a) Pulpotomy

b) Root canal therapy Reimbursement includespre-operative, operative and post-operative X-rays,bacteriologic cultures, diagnostic tests, localanesthesia and routine ollow-up care, limited toone time on the same tooth

c) Root canal retreatment Reimbursement includespre-operative, operative and post-operative X-rays,

bacteriologic cultures, diagnostic tests, local anesthesiaand routine ollow-up care per ormed not less than 12months a ter the initial therapy, limited to one timeon the same tooth per 12-month period

d) Apicoectomy/periradicular surgery (anterior,bicuspid, molar, each additional root), paid as aseparate bene t only i services are per ormed notless than 12 months a ter the initial root canal

IMPORTANT INFORMATION

Dental and vision coverage is only included inthe Health Net Life Insurance PPO Plus plans.

You must enroll in a PPO Plus plan to obtaindental and vision coverage.



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therapy is completed Reimbursement includespre-operative, operative and post-operative X-rays,bacteriologic cultures, diagnostic tests, localanesthesia and routine ollow-up care

e) Periodontal scaling and root planing (per quadrant),limited to one time per quadrant per 24-month

period and only i not per ormed on the same dateo service as a prophylaxis or any other periodontalprocedure

) For non-surgical periodontal procedures that arequadrant-based and when there are less than 5teeth remaining in the quadrant and the need fortreatment is indicated, as determined by Health NetLi e, payment will be provided at 50 percent o thefull quadrant rate. A maximum of 2 quadrants ofperiodontal procedures will be paid on the same date

o service unless supported with documentation ormedical need

g) For surgical periodontal procedures that arequadrant-based and when there are less than 3 teethrequiring treatment, as determined by Health NetLi e, payment will be provided at 50 percent o thefull quadrant rate. A maximum of 2 quadrants ofperiodontal procedures will be paid on the same dateo service unless supported with documentation ormedical need

h) Periodontal surgery related services as listed below,limited to:

• One (1) time per quadrant of the mouth in any 36-month period with charges combined orgingivectomy, gingival curettage, or osseoussurgery performed in the same quadrant withinthe same 36-month period

i) Oral surgery services as listed below, includingan allowance or local anesthesia and routinepostoperative care:

• Simple extraction;

• Surgical extractions of erupted or impacted teeth;

• Alveoloplasty; and

• Excision of hyperplastic tissue – per arch.

j) General anesthesia and intravenous sedation iscovered only in conjunction with the extraction o impacted teeth, limited as ollows:

• Considered for payment as a separate bene t only when Medically Necessary as determined by Health Net Li e

k) Specialist consultation.

3. Type II: Basic dental services (Restorative)

Coverage is provided or the ollowing restorative basicdental services and subject to the ollowing limitations:

a) Amalgam restorations inclusive o any etching andbonding, limited as ollows:

• Multiple restorations (surfaces) on a single tootare combined or coverage purposes

•Bene ts for the replacement of an existingamalgam restoration will only be considered orpayment i at least 12 months have passed sincethe existing amalgam restoration was placed

• Acid etch is not covered as a separate procedu

b) Composite restorations inclusive o any etching andbonding, limited as ollows:

• Multiple restorations (surfaces) on a single antetooth are combined or coverage purposes

• Acid etch is not covered as a separate procedu

• Bene ts for the replacement of an existing anterior composite restoration will only beconsidered or payment i at least 12 monthshave passed since the existing anterior compositerestoration was placed

• Bene ts for composite resin restorations onposterior teeth (behind the second bicuspid) will

be based on the allowance or the correspondingamalgam restoration

c) Stainless steel crowns are limited to one per tooper 36-month period or members age 19 andunder or teeth not restorable by an amalgam orcomposite lling



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4. Type III: Major dental services

Coverage is provided or the ollowing major dentalservices and subject to the ollowing limitations:

a) Inlays and onlays:

• Are covered only when the tooth cannot be

restored by an amalgam lling• Are covered only if more than 5 years have elapsed

since last placement; and

• Limited to persons age 19 and above.

• Composite or porcelain is not covered on molar teeth

b) Porcelain substrate or metal crowns:

• Porcelain or porcelain fused to metal crowns are

not covered on molar teethc) Crowns:

• Are covered only when the tooth cannot berestored by an amalgam or composite lling

• Are covered only if more than 5 years have elapsedsince last placement; and

• Limited to persons over age 19.

d) Crown build-up, including pins and pre- abricated

posts. (Current periapical X-ray and narrative shouldindicate insu cient remaining tooth structureCoverage is subject to determination o dentalnecessity )

e) Post and core, covered only or endodontically treated teeth requiring crowns.

) Full dentures, 1 time per arch, limited as ollows:

• Replacement dentures are covered only if:

1 Five (5) years have elapsed since last placementand the denture cannot be made serviceable;and

2 Two (2) years have elapsed a ter the member’se ective date o coverage under the Dental Plan

g) Health Net Li e will not pay additional bene ts orpersonalized dentures or overdentures and associatedtreatment

h) Partial dentures, including any clasps and rests andall teeth, 1 partial per arch, limited as ollows:

• Replacement partial dentures are covered onl

1 Five (5) years have elapsed since lastplacement (please re er to the Denture orBridge Replacement/Addition provision forexceptions) and the partial denture cannot bemade serviceable; and


i) There is no bene t or precision or semi-precisionattachments

j) Each additional clasp and rest

k) Full or partial dentures, adjustments limited to one

time per arch in any 12-month period ollowing theinitial 6-month denture placement period

l) One repair per arch to ull or partial dentures andbridges limited to repairs per ormed more than 12months a ter the initial insertion; repairs are limitedto those resulting rom normal wear and to onerepair every 12 months

m) Relining or rebasing dentures, limited to:

• One (1) time per arch per 36-month period;

• For standard dentures, when done within 12months o the insertion o the denture

• For immediate dentures, when done within 6months a ter the insertion o the denture

n) Stayplates (temporary partial dentures) are limitedto the replacement o anterior teeth and only duringthe healing phase ollowing extractions

o) Bene ts or the replacement o an existing xedpartial denture are payable only i the existing bridge:

1 Is more than 5 years old (see the Denture orBridge Replacement/Addition provision forexceptions);

2 Cannot be made serviceable; and



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• A xed partial denture is the bene t for the replacement o a missing single toothonly i there are no other missing teeth in thesame arch

• A removable partial denture is the bene t forthe replacement o more than 1 missing toothin the same arch, limited to one per 5 years

5. Denture or bridge replacement/addition

Health Net Li e will not pay or the replacement o a ulldenture, partial denture, xed partial denture or or teethadded to a partial denture unless:

a) Five (5) years have elapsed since last replacement o the denture or bridge;

b) The denture or bridge cannot be made serviceable;

c) The denture or bridge was damaged while in themember’s mouth when an injury was su ered whileinsured under the Policy, and it cannot be madeserviceable; and

d) Two (2) years have elapsed a ter the member’se ective date o coverage under the Dental PlanHowever, the ollowing exceptions will apply:

• Bene ts or the replacement o an existing partial

denture that is less than 5 years old will be coveredi there is a dentally necessary extraction o anadditional unctioning natural tooth and thepartial denture cannot be made serviceable

• For an existing xed partial denture that is lessthan 5 years old, and an existing abutment or a

unctioning natural tooth within the same arch isextracted, the covered bene t will be apartial denture

6. Missing teeth limitationHealth Net Li e will not pay bene ts or replacement o teeth missing on you or your dependents’ e ective dateo coverage or the purpose o the initial placement o a ull denture, partial denture or xed partial denture(bridge), except as ollows:

a) The initial placement o ull or partial dentures will be considered a covered dental charge i theplacement includes the initial replacement o a

unctioning natural tooth extracted while themember is insured under the Policy

b) The initial placement o a xed partial denture will be considered a covered dental charge i theplacement includes the initial replacement o a

unctioning natural tooth extracted while the

member is insured under the Policy However, theollowing restrictions will apply:

• Bene ts will only be covered for the replacemo the teeth extracted while the member is coveredunder the Policy and the replacement is urnished

within 12 months o the date the tooth wasrst extracted

• Bene ts will not be covered for the replaceme o other teeth that were missing on the member’se ective date Please re er to the Type III: MajorDental Services section of the Policy for furthin ormation

General exclusionsHealth Net Li e will not pay expenses incurred or any othe ollowing:

1 Treatment that is: (a) not included in the DentalPlan Schedule of Bene ts; (b) not dentally neces or (c) Experimental in nature

2.Services and supplies related to the change of vdimension, restoration or maintenance o occlusion,re-implantation, splinting and stabilizing teeth,bite registration, bite analysis, attrition, erosion orabrasion, and treatment or myo ascial paindisorders (MPD) or temporomandibular jointdisorders (TMJ).

3.Services and supplies provided primarily for cosmpurposes

4.Crowns, inlays, cast restorations or other laboratoprepared restorations on teeth that may be restored with an amalgam or composite resin lling

5 Athletic mouthguards; denture duplication; in ectioncontrol; separate charges or acid etch; treatment o jaw fractures; orthognathic surgery; exams requireby a third party; travel time; transportation costs;pro essional advice given on the phone



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6 Implants, related procedures or services involvingroot orm implants

7 Gra ting (bone or tissue) and guided tissueregeneration

8 Prescription drugs or any medications arenot covered

9.Services, procedures or supplies for which a charge would not have been made in the absence o insurance

10 Procedures, services or supplies or which themember does not have to pay, except when paymentof such bene ts is required by law and then only tothe extent required by law.

11 Treatment will be considered a covered service andsupply only when the member is eligible or serviceson the date treatment is started Payment is based onthe start date

12. Services and supplies obtained while outside theUnited States, except for emergency dental care.

13 Orthodontic services, supplies, or oral surgery procedures or the purposes o orthodontictreatment, inclusive o extractions

vision

The ollowing is a selective listing only For acomprehensive listing see the Health Net PPO policy

1 Charges or procedures, services or materials that arenot included as covered charges

2 Any portion o a charge in excess o the maximumbene t allowance

3 Expenses or any non-standard corrective lensmaterials, including but not limited to the ollowing:coated, dyed, glass lens tints or laminated lenses,blended, or oversize lenses, occupational orrecreational lenses, polycarbonate, sa ety glasses,scratch resistant, UV protection, anti-re ective, orphotochromatic/photosensitive lenses.

4. Non-prescription lenses.

5 Orthoptics, vision training and low vision aids andany associated supplemental testing

6 Medical or surgical treatment o the eye including,but not limited to, Laser In Situ Keratomileusis(LASIK) and Photorefractive Keratectomy (PRK).

7 Prescription or non-prescription medications

8 Any eye examination or any corrective eyewearrequired as a condition of employment.

9.Services or materials which the company determito be experimental, cosmetic or not medically necessary

10 Any service or material not prescribed by anophthalmologist, optometrist or registereddispensing optician

11. Services and materials furnished in conjunction wexcluded services and materials

12. Services and materials for repair or replacemento broken, lost or stolen lenses, contact lenses or

rames

13. Services and materials that a Covered Personreceived during a service interval under any other plan o ered by the company or one o thecompany’s a liates

14. Charges incurred before a Covered Person’s effecdate o coverage under the Policy or a ter such

coverage terminates15. Services or materials received as a result of dise

de ect or injury due to war or an act o war (declaredor undeclared), taking part in a riot or insurrection,or committing or attempting to commit a elony

16. Services and materials obtained while outside theUnited States, except for emergency vision care.

17. Services or materials resulting from or in the coo your or a dependent’s regular occupation or pay

or pro t or which you or your dependent is entitledto bene ts under any Worker’s Compensation law,employer’s liability law or similar law You mustpromptly claim and noti y the company o all suchbene ts



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18 As ollows:

• Charges payable or reimbursable by or througha plan or program o any governmental agency,except i the charge is related to a non-military service disability and treatment is provided by a governmental agency of the United States.

However, Health Net Li e will always reimburseany state or local medical assistance (Medicaid)agency or covered services and materials

• Charges not imposed against the person or for which the person is not liable

19. Services, procedures or materials for which a charge would not have been made in the absenceo insurance

Prior authorizationCertain vision services require prior authorization byHealth Net Li e in order to be covered This means thatthe vision provider must contact Health Net Li e torequest that the service be approved before it is proRequests for prior authorization will be denied if therequested service is not Medically Necessary.



Documents

Health Net PPO Health Insurance Plans Individuals Families CA 2011