summaries - californiachoice€¦ · 1/1/2014 · californiachoice ® benefit summaries under the...

SUMMARIES

The benefits listed in this brochure were collected from all plans participating in the CaliforniaChoice Program and are accurate to the best of our knowledge at the time of print. If the information in this brochure differs from the information in the SBC (Summary of Benefits and Coverage), EOC (Evidence of Coverage) or COI (Certificate of Insurance), the EOC or COI applies.

CaliforniaChoice ® Benefit Summaries Under the Affordable Care Act (ACA), health benefits are divided into four metal tiers (Platinum, Gold, Silver, and Bronze). Each tier offers a variety of health plans and benefits to choose from. There are two options to choose from when determining which tier or tiers to offer.

1. Single Metal Tier Offer employees access to the health plans and benefits available in a single tier.2. Tiered Choice O ffer employees access to the health plans and benefits available in two neighboring metal tiers:

Employees use their employer’s contribution and apply it to the health plan and benefit they prefer. If the employee selects a plan that is more than their employer’s contribution, they simply pay the difference. And, there’s just ONE employer application, ONE consolidated monthly bill, and ONE toll-free number.

TABLE OF Contents

Bronze PPO

Bronze HMO & EPO

Silver HMO & EPO

Gold PPO

Gold HMO

Silver PPO

Platinum HMO 3

9

17

23

31

35

41

3

Services HMO A HMO A HMO A

Participating Health Plans Aetna Anthem Blue Cross Health Net

Network Name Aetna Value Network Select HMO Salud HMO y Mas

Metal Tier Platinum Platinum Platinum

Calendar Year Deductible* None None None

Out-of-Pocket Max Ind/Fam $4,000 / $8,000 11 $2,000 / $4,000 11 $2,000 / $4,000 4

Lifetime Maximum Unlimited Unlimited Unlimited

Dr. Office Visits (PCP) $20 Copay $10 Copay $20 Copay

Specialist Visit (SPC) $40 Copay $10 Copay $20 Copay

Laboratory $20 Copay 100% $20 Copay

X-Ray $40 Copay 100% $20 Copay

MRI, CT and PET $150 Copay $150 Copay per test $20 Copay per procedure

Hospital Services – In-Patient $250 Copay per day – 5 days max $450 Copay per day – 4 days max $400 Copay per day – 4 days max

In-Patient Physician Fees 100% 100% 100%

Emergency Room(copay waived if admitted)

$150 Copay $150 Copay $100 Copay

Urgent Care $40 Copay $10 Copay $20 Copay

Hospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center

$250 Copay$250 Copay



Hospital Pre-Authorization Required Required Required

2nd Surgical Opinion $40 Copay $10 Copay $20 Copay

Ambulance Services (per trip) $150 Copay 90% $50 Copay

Rx BenefitsGenericFormulary BrandNon-Formulary Brand

$5 Copay 10

$15 Copay 10

$25 Copay 10

$5 Copay$30 Copay$60 Copay

$10 Copay 7, 8

$20 Copay 7, 8

$50 Copay 7, 8

Oral Contraceptives 100% (generic only) 100% 100%

Pre-Existing Conditions Covered Covered Covered

Maternity and Newborn Care Covered as any Illness Covered as any Illness Covered as any Illness

Preventive/Wellness Services 5 100% 100% 100%

Chronic Disease Management Covered as any Illness $10 Copay $20 Copay

Chiropractic (20 visits max per year) Not Covered $10 Copay Not Covered

Acupuncture $15 Copay 1

12 visits max per year$10 Copay $20 Copay 2

Physical, Occupational,Speech Therapy


Rehabilitative & HabilitativeServices and Devices


Home Health Care(Max 100 visits per year)

$20 Copay $10 Copay 13 100%

PlatinumBenefit Summaries HMO

4

Services HMO A HMO A HMO A

Participating Health Plans Aetna Anthem Blue Cross Health Net

Network Name Aetna Value Network Select HMO Salud HMO y Mas

Metal Tier Platinum Platinum PlatinumSkilled Nursing Facility PerDisability (Max 100 days per year)

$150 Copay per day – 5 days max 100% $400 Copay per day4 days max (no limit)

Hospice 100% 100% 100%

Durable Medical Equipment(Covered when medically necessary as determined by HCSP)

90% 90% 70%

Mental HealthIn-PatientOut-Patient

$250 Copay per day – 5 days max$20 Copay


$400 Copay per day 6 – 4 days max$20 Copay 6

Drug/Substance AbuseIn-Patient (Detox Only) $250 Copay per day – 5 days max $450 Copay per day – 4 days max $400 Copay per day – 4 days max

Infertility Evaluation and Treatment See Plan Specific EOC Not Covered 50% 3

Pediatric VisionCarrierNetworkExamContact LensesFramesMaximum Allowance per year

EyeMedEyeMed100%100% (Pref. Provider)100% (Pref. Provider)1 per 12 month period

Anthem VisionBlue View Vision100%100% (in lieu of eyeglasses)100%1 per calendar year

EyeMed 12

EyeMed100%100%1 per calendar yearNone

Pediatric DentalCarrier NetworkDeductibleOut-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)

AetnaPPONone$1,000 / $2,000100%100%80%50%50%

Pediatric Dental HMOPrime $60$1,000100%100%50%50%50%

Dental Benefit Providers 9, 12

Dental Benefit ProvidersNoneCombined with Medical$20 Copay100%$95 Copay$365 Copay$1,000 Copay

Benefit Summaries (cont.)HMO

Platinum

* All services are subject to the deductible unless otherwise stated. 1. Unlimited visits for treatment of nausea or as part of a comprehensive pain management program and for anesthesia. 2. Must be medically necessary. 3. Infertility drugs limited to a lifetime benefit maximum of $1,500. 4. The OOPM is combined for SIMNSA networks in Mexico and California. 5. See plan specific EOC for information on preventive services. 6. Benefits are administered by MHN Services, an affiliate behavioral health administrative services company which provides behavioral health services. 7. The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. 8. See plan specific EOC for information regarding preventive drugs and women’s contraceptives. 9. The pediatric dental benefits are provided by Health Net and administered by Dental Benefit Providers of California, Inc. (DBP). DBP is a California licensed specialized dental plan and is not affiliated with Health Net. Additional pediatric dental benefits are covered. See the plan’s EOC for details. 10. Pharmacy tiers are Tier 1: Preferred Generic, Tier 2: Preferred Brand, Tier 3: Non-Preferred.11. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.12. Pediatric dental and vision are included on all plans.13. Limited to 100 4-hour visits per year.

5

Services HMO A HMO A HMO B

Participating Health Plans Kaiser Permanente Sharp Sharp

Network Name Full Premier Performance

Metal Tier Platinum Platinum Platinum


Out-of-Pocket Max Ind/Fam $4,000 / $8,000 $3,500 / $7,000 4 $3,000 / $6,000 4




Laboratory $20 Copay 100% 100%

X-Ray $40 Copay 100% 100%

MRI, CT and PET $150 Copay per procedure $150 Copay per procedure $100 Copay per procedure

Hospital Services – In-Patient $250 Copay per day – 5 days max $400 Copay 85%



$150 Copay $150 Copay 85%




80%80%

85%85%



Ambulance Services (per trip) $150 Copay $100 Copay 85%


$5 Copay$15 Copay$15 Copay (prior approval)



Oral Contraceptives 100% 100% (if in formulary) 100% (if in formulary)




Chronic Disease Management $40 Copay $20 Copay $30 Copay

Chiropractic (20 visits max per year) Not Covered Not Covered Not Covered

Acupuncture $40 Copay $20 Copay $30 Copay






100% 1 $20 Copay (100 days per year)

$30 Copay(100 days per year)

PlatinumBenefit Summaries HMO

6

Services HMO A HMO A HMO B



Metal Tier Platinum Platinum PlatinumSkilled Nursing Facility PerDisability (Max 100 days per year)

$150 Copay per day – 5 days max $200 Copay 85%

Hospice 100% 100% 100%


90% 50% 50%



$400 Copay$20 Copay

85%$30 Copay

Drug/Substance AbuseIn-Patient (Detox Only) $250 Copay per day – 5 days max $400 Copay 85%

Infertility Evaluation and Treatment Not Covered 50% of allowed charges 50% of allowed charges

Pediatric VisionCarrierNetworkExamContact LensesFrames

Maximum Allowance per year

Kaiser PermanenteKaiser Permanente100%1 pair per calendar year1 pair per calendar year

None

VSPVSP100%1 pair in lieu of eyeglasses100% (Pediatric Exchangecollection only)None

VSPVSP100%1 pair in lieu of eyeglasses100% (Pediatric Exchangecollection only) None


Delta DentalDeltaCare USANone$1,000100%100%$40 Copay 2

$365 Copay 3

$1,000 Copay

Premier AccessAccess Dental DHMONone$1,000 / $2,000$20 Copay100%$95 Copay 2

$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay


Platinum

* All services are subject to the deductible unless otherwise stated.1. Home Health Care visit part-time/intermittent coverage (2 hour(s) maximum per visit(s), 3 visit(s) maximum per day(s), 100 visit(s) maximum per calendar year).2. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan's average copay charged for procedures in this category cannot exceed the stated amount.3. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for procedures in this category cannot exceed the stated amount. 4. Individuals enrolled in a family plan will reach the annual deductible or out-of-pocket maximum if the member meets the individual deductible or out-of-pocket

maximum amount or any combination of enrolled family members meets the family deductible or out-of-pocket maximum amount, whichever comes first. Amounts paid toward the deductible apply toward the out-of-pocket maximum.

5. See plan specific EOC for information on preventive services.

7

Platinum

Services HMO A

Participating Health Plans Western Health Advantage

Network Name Full

Metal Tier PlatinumCalendar Year Deductible* None

Out-of-Pocket Max Ind/Fam $4,000 / $8,000 1

Lifetime Maximum Unlimited

Dr. Office Visits (PCP) $25 Copay

Specialist Visit (SPC) $25 Copay

Laboratory 100%

X-Ray 100%

MRI, CT and PET $100 Copay per test

Hospital Services – In-Patient $250 Copay per day – Days 1-5

In-Patient Physician Fees 100%


$100 Copay

Urgent Care $50 Copay



Hospital Pre-Authorization Not Required

2nd Surgical Opinion $25 Copay

Ambulance Services (per trip) 100%



Oral Contraceptives 100%

Pre-Existing Conditions Covered

Maternity and Newborn Care Covered as any Illness

Preventive/Wellness Services 2 100%

Chronic Disease Management Covered as any Illness

Chiropractic (20 visits max per year) Not Covered

Acupuncture $15 Copay

Physical, Occupational, Speech Therapy $25 Copay


$25 Copay


100%

Benefit Summaries HMO

8

Services HMO A

Participating Health Plans Western Health Advantage

Network Name Full

Metal Tier PlatinumSkilled Nursing FacilityPer Disability (Max 100 days per year)

$250 Copay per day – Days 1-5

Hospice 100%

Durable Medical Equipment(Covered when medically necessaryas determined by HCSP)

80% 3,4


$250 Copay per day – Days 1-5$25 Copay

Drug/Substance AbuseIn-Patient (Detox Only) $250 Copay per day – Days 1-5

Infertility Evaluation and Treatment Not Covered


MES VisionFull100%100%100%1 per calendar year


Access DentalFullNone$1,000 / $2,000100%100%$40 Copay 5

$365 Copay 6

$1,000 Copay


Platinum

* All services are subject to the deductible unless otherwise stated.1. The annual out-of-pocket maximum is the total amount the member must pay for certain services in a calendar year.2. There may be an office visit copay if the primary purpose of a visit is not preventive or other services are provided. See plan specific EOC for information on preventive services.3. Percentage copayment amounts are based on WHA’s contracted rates with the provider of service.4. See copayment summary for applicable prosthetic/orthotic device copayment amount.5. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for procedures in this category cannot exceed the stated amount.6. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for procedures in this category cannot exceed the stated amount.

9

Services HMO A HMO B HMO A

Participating Health Plans Aetna Aetna Anthem Blue Cross

Network Name Aetna Value Network Aetna Value Network Select HMO

Metal Tier Gold Gold Gold

Calendar Year Deductible * None None None

Out-of-Pocket Max Ind/Fam 4 $4,500 / $9,000 $5,000 / $10,000 $5,500 / $11,000




Laboratory $20 Copay $30 Copay 100%

X-Ray $60 Copay $60 Copay 100%

MRI, CT and PET $250 Copay $250 Copay $150 Copay per test

Hospital Services – In-Patient $750 Copay $500 Copay per day3 days max

$750 Copay per day4 days max













$20 Copay (ded waived) 2

$250 Ded – $50 Copay 2

$250 Ded – 50% up to $500 2


$250 Ded – $50 Copay 2

$250 Ded – 50% up to $500 2

$15 Copay (ded waived) $300 / $600 Ded – $35 Copay$300 / $600 Ded – $70 Copay

Oral Contraceptives 100% (generic only) 100% (generic only) 100%




Chronic Disease Management Covered as any Illness Covered as any Illness $35 Copay

Chiropractic (20 visits max per year) $15 Copay $15 Copay $35 Copay

Acupuncture $15 Copay 1

12 visits max per year$15 Copay 1

12 visits max per year$35 Copay






$20 Copay $30 Copay $35 Copay 5

GoldBenefit Summaries HMO

10



Network Name Aetna Value Network Aetna Value Network Select HMO

Metal Tier Gold Gold GoldSkilled Nursing Facility PerDisability (Max 100 days per year)

$750 Copay $500 Copay per day – 3 days max 100%

Hospice 100% 100% 100%


80% 80% 80%


$750 Copay$60 Copay



Drug/Substance AbuseIn-Patient (Detox Only) $750 Copay $500 Copay per day – 3 days max $750 Copay per day – 4 days max

Infertility Evaluation and Treatment See Plan Specific EOC See Plan Specific EOC Not Covered


EyeMedEyeMed$60 Copay100% (Pref. Provider)100% (Pref. Provider)1 per calendar year

EyeMedEyeMed$60 Copay100% (Pref. Provider)100% (Pref. Provider)1 per calendar year



AetnaPPONone$1,000 / $2,000100%100%70%50%50%

AetnaPPONone$1,000 / $2,000100%100%70%50%50%

Pediatric Dental HMOPrime$60$1,000100%100%50%50%50%

GoldBenefit Summaries (cont.)HMO

* All services are subject to the deductible unless otherwise stated.1. Unlimited visits for treatment of nausea or as part of a comprehensive pain management program and for anesthesia.2. Pharmacy tiers are Tier 1: Preferred Generic, Tier 2: Preferred Brand, Tier 3: Non-Preferred.3. See plan specific EOC for information on preventive services.4. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.5. Limited to 100 4-hour visits per year.

11

Services HMO B HMO A HMO B

Participating Health Plans Anthem Blue Cross Health Net Health Net

Network Name Select HMO WholeCare WholeCare



Out-of-Pocket Max Ind/Fam $5,000 / $10,000 9 $4,500 / $9,000 $4,500 / $9,000




Laboratory 100% $25 Copay $40 Copay

X-Ray 100% $25 Copay $40 Copay

MRI, CT and PET $150 Copay per test $100 Copay per procedure $100 Copay per procedure

Hospital Services – In-Patient $650 Copay per day – 4 days max $500 Copay per day – 4 days max 60%








60%60%



Ambulance Services (per trip) 80% $200 Copay $200 Copay



$20 Copay (ded waived) 5, 7

$200 Ded – $30 Copay 5, 6, 7

$200 Ded – $50 Copay 5, 6, 7

$20 Copay (ded waived) 5, 7

$200 Ded – $30 Copay 5, 6, 7

$200 Ded – $50 Copay 5, 6, 7

Oral Contraceptives 100% 100% 100%





Chiropractic (20 visits max per year) $30 Copay Not Covered Not Covered

Acupuncture $30 Copay $40 Copay 1 $40 Copay 1






$30 Copay 11 $50 Copay $50 Copay


12

Services HMO B HMO A HMO B

Participating Health Plans Anthem Blue Cross Health Net Health Net

Network Name Select HMO WholeCare WholeCare


100% $500 Copay per day4 days max (no limit)

60% (no limit)

Hospice 100% 100% 100%


80% 70% 70%



$500 Copay per day 4 – 4 days max$40 Copay 4

60% 4

$40 Copay 4

Drug/Substance AbuseIn-Patient (Detox Only) $650 Copay per day – 4 days max $500 Copay per day – 4 days max 60%

Infertility Evaluation and Treatment Not Covered 50% 2 Not Covered



EyeMed 10


EyeMed 10









* All services are subject to the deductible unless otherwise stated.1. Must be medically necessary.2. Infertility drugs limited to a lifetime benefit maximum of $1,500.3. See plan specific EOC for information on preventive services.4. Benefits are administered by MHN Services, an affiliate behavioral health administrative services company which provides behavioral health services.5. The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary.6. The brand-name prescription drug deductible (per member, per calendar year) must be paid before Health Net begins to pay for brand-name prescription drugs.7. See plan specific EOC for information regarding preventive drugs and women’s contraceptives.8. The pediatric dental benefits are provided by Health Net and administered by Dental Benefit Providers of California, Inc. (DBP). DBP is a California licensed specialized dental plan and is not affiliated with Health Net. Additional pediatric dental benefits are covered. See the plan’s EOC for details.9. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.10. Pediatric dental and vision are included on all plans.11. Limited to 100 4-hour visits per year.

13


Participating Health Plans Kaiser Permanente Kaiser Permanente Sharp

Network Name Full Full Performance


Calendar Year Deductible* $500 / $1,000 6 None None

Out-of-Pocket Max Ind/Fam $6,350 / $12,700 7 $6,350 / $12,700 $6,350 / $12,700 4


Dr. Office Visits (PCP) $30 Copay (ded waived) $30 Copay $20 Copay

Specialist Visit (SPC) $30 Copay (ded waived) $50 Copay $45 Copay

Laboratory $20 Copay (ded waived) $30 Copay 100%

X-Ray $20 Copay (ded waived) $50 Copay 100%

MRI, CT and PET $250 Copay per procedure (ded waived)

$250 Copay per procedure $175 Copay per procedure




$250 Copay $250 Copay 75%

Urgent Care $30 Copay (ded waived) $30 Copay $45 Copay




75%75%





$20 Copay (overall ded waived)$50 Copay (overall ded waived)$50 Copay (overall ded waived; prior approval)


$19 Copay (ded waived)$150 / $300 Ded – $35 Copay$150 / $300 Ded – $70 Copay

Oral Contraceptives 100% 100% 100% (if in formulary)



Preventive/Wellness Services 5 100% (ded waived) 100% 100%



Acupuncture $30 Copay (ded waived) $50 Copay $45 Copay


$30 Copay (ded waived) $30 Copay $45 Copay




100% (ded waived) 1 100% 1 $45 Copay(100 days per year)


14



Network Name Full Full Performance


$250 Copay per day – 5 days max $300 Copay per day – 5 days max 75%

Hospice 100% (ded waived) 100% 100%


80% (ded waived) 80% 50%


$600 Copay per day – 5 days max$30 Copay (ded waived)


75%$45 Copay


Infertility Evaluation and Treatment Not Covered Not Covered 50% of allowed charges



Kaiser PermanenteKaiser Permanente100% (ded waived)1 pair per calendar year1 pair per calendar year (ded waived)

None

Kaiser PermanenteKaiser Permanente100%1 pair per calendar year1 pair per calendar year

None



Delta DentalDeltaCare USANone$1,000100%100% (ded waived)$40 Copay 2

$365 Copay 3

$1,000 Copay

Delta DentalDeltaCare USANone$1,000100%100%$40 Copay 2

$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay


* All services are subject to the deductible unless otherwise stated.1. Home Health Care visit part-time/intermittent coverage (2 hour(s) maximum per visit(s), 3 visit(s) maximum per day(s), 100 visit(s) maximum per calendar year).2. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for procedures in this category cannot exceed the stated amount.3. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for procedures in this category cannot exceed the stated amount.4. Individuals enrolled in a family plan will reach the annual deductible or out-of-pocket maximum if the member meets the individual deductible or out-of-pocket


5. See plan specific EOC for information on preventive services.6. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.7. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.

15

Services HMO B HMO A

Participating Health Plans Sharp Western Health Advantage

Network Name Premier Full

Metal Tier Gold Gold

Calendar Year Deductible* None None

Out-of-Pocket Max Ind/Fam $6,350 / $12,700 7 $6,350 / $12,700 1

Lifetime Maximum Unlimited Unlimited

Dr. Office Visits (PCP) $25 Copay $40 Copay

Specialist Visit (SPC) $60 Copay $40 Copay

Laboratory $25 Copay $40 Copay

X-Ray $60 Copay $40 Copay

MRI, CT and PET $175 Copay per procedure $250 Copay per test

Hospital Services – In-Patient $450 Copay per day – 5 days max $500 Copay per day

In-Patient Physician Fees 100% 100%


$200 Copay $250 Copay

Urgent Care $60 Copay $100 Copay


75%75%


Hospital Pre-Authorization Required Not Required

2nd Surgical Opinion $60 Copay $40 Copay

Ambulance Services (per trip) $150 Copay 100%




Oral Contraceptives 100% (if in formulary) 100%

Pre-Existing Conditions Covered Covered

Maternity and Newborn Care Covered as any Illness Covered as any Illness

Preventive/Wellness Services 8 100% 100% 2

Chronic Disease Management $60 Copay Covered as any Illness

Chiropractic (20 visits max per year) Not Covered Not Covered

Acupuncture $60 Copay $15 Copay


$60 Copay $40 Copay


$60 Copay $40 Copay


$60 Copay(100 days per year)

100%

Benefit Summaries HMOGold

16



Network Name Premier Full

Metal Tier Gold GoldSkilled Nursing Facility PerDisability (Max 100 days per year)

$200 Copay per day $500 Copay per day

Hospice 100% 100%


50% 80% 3,4



$500 Copay per day$40 Copay

Drug/Substance AbuseIn-Patient (Detox Only) $450 Copay per day – 5 days max $500 Copay per day

Infertility Evaluation and Treatment 50% of allowed charges Not Covered



VSPVSP100%1 pair in lieu of eyeglasses100% (Pediatric Exchange collection only)None

MES VisionFull100%100%100%

1 per calendar year



$365 Copay 6

$1,000 Copay

Access DentalFullNone$1,000 / $2,000100%100%$40 Copay 5

$365 Copay 6

$1,000 Copay


* All services are subject to the deductible unless otherwise stated.1. The annual out-of-pocket maximum is the total amount the member must pay for certain services in a calendar year.2. There may be an office visit copay if the primary purpose of a visit is not preventive or other services are provided. 3. Percentage copayment amounts are based on WHA’s contracted rates with the provider of service.4. See copayment summary for applicable prosthetic/orthotic device copayment amount.5. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data,

the plan’s average copay charged for procedures in this category cannot exceed the stated amount.6. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data,

the plan’s average copay charged for procedures in this category cannot exceed the stated amount.7. Individuals enrolled in a family plan will reach the annual deductible or out-of-pocket maximum if the member meets the individual

deductible or out-of-pocket maximum amount or any combination of enrolled family members meets the family deductible or out-of-pocket maximum amount, whichever comes first. Amounts paid toward the deductible apply toward the out-of-pocket maximum.


17

* All services are subject to the deductible unless otherwise stated. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.

1. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.

Services PPO A PPO B

Participating Health Plans Anthem Blue Cross Anthem Blue Cross

Network Name Advantage PPO Select PPO

Metal Tier Gold GoldIn-Network Out-of-Network In-Network Out-of-Network

Calendar Year Deductible* $500 / $1,000 $1,000 / $2,000 $750 / $1,500 $1,500 / $3,000Out-of-Pocket Max Ind/Fam 1 $3,500 / $7,000 $7,000 / $14,000 $3,500 / $7,000 $7,000 / $14,000Lifetime Maximum Unlimited UnlimitedDr. Office Visits (PCP) $25 Copay (first 3 visits) – 80% 50% $25 Copay (ded waived) 50%Specialist Visit (SPC) $25 Copay (first 3 visits) – 80% 50% $50 Copay (ded waived) 50%Laboratory 80% 50% 80% 50%X-Ray 80% 50% 80% 50%MRI, CT and PET 80% 50% (up to $800 per test) 80% 50% (up to $800 per test)Hospital Services –In-Patient

Tier 1: 80%Tier 2: $500 Copay – 80%

50% (up to $650 per day) 80% 50% (up to $650 per day)

In-Patient Physician Fees 80% 50% 80% 50%Emergency Room(copay waived if admitted)

80% 80% $200 Copay – 80% $200 Copay – 80%

Urgent Care 80% 50% $50 Copay (ded waived) 50%Hospital Services –Out-PatientSurgical Facility

Ambulatory Surgery Center

Tier 1: 80%Tier 2: $250 Copay – 80%80%

50% (up to $380 per admit)


80%

80%


50% (up to $380 per admit)Hospital Pre-Authorization Required Required2nd Surgical Opinion $25 Copay (ded waived) 50% $50 Copay (ded waived) 50%Ambulance Services (per trip) 80% 80% 80% 80%Rx BenefitsGenericFormulary BrandNon-Formulary Brand

$15 Copay 2

$35 Copay 2

$70 Copay 2


$250 / $500 Ded – $35 Copay 2

$250 / $500 Ded – $70 Copay 2

Oral Contraceptives 100% 100%Pre-Existing Conditions Covered CoveredMaternity and Newborn Care Covered as any Illness Covered as any IllnessPreventive/Wellness Services 3 100% (ded waived) 50% 100% (ded waived) 50%Chronic Disease Management 80% 50% 80% 50%Chiropractic(20 visits max per year)

$25 Copay (first 3 visits) – 80% 50% (up to $25 per visit) $25 Copay (ded waived) 50% (up to $25 per visit)

Acupuncture $25 Copay (first 3 visits) – 80% 50% $25 Copay (ded waived) 50%Physical, Occupational, Speech Therapy

$25 Copay (first 3 visits) – 80% 50% (up to $25 per visit for PT / OT)

$25 Copay (ded waived) 50% (up to $25 per visit for PT / OT)

GoldBenefit Summaries PPO

18

GoldBenefit Summaries (cont.)PPO





Rehabilitative & Habilitative Services and Devices




80% 4 50% (up to $75 per visit) 4 $25 Copay (ded waived) 4 50% (up to $75 per visit) 4

Skilled Nursing FacilityPer Disability(Max 100 days per year)

Tier 1: 80%Tier 2: $500 Copay – 80%


Hospice 100% 50% 100% 50%Durable MedicalEquipment (Covered when medically necessary as determined by HCSP)

80% 50% 80% 50%

Mental HealthIn-Patient

Out-Patient

Tier 1: 80%Tier 2: $500 Copay – 80%$25 Copay (first 3 visits) – 80%

50% (up to $650 per day)

50%

80%

$25 Copay (ded waived)


50%Drug/Substance AbuseIn-Patient (Detox Only)

Tier 1: 80%Tier 2: $500 Copay – 80%


Infertility Evaluation and Treatment

Not Covered Not Covered

Pediatric VisionCarrierNetworkExamContact Lenses

Frames


Anthem VisionBlue View Vision100% (ded waived)100% (in lieu of eyeglasses)

100% (1 per calendar year)(ded waived)1 per calendar year

Anthem Vision

$30 Reimbursement$60 Reimbursement (in lieu of eyeglasses)$45 Reimbursement (1 per calendar year)1 per calendar year



Anthem Vision



Pediatric Dental PPOPrime$60 (combined IN & OON)$1,000100%100%50%50%50%

Pediatric Dental PPO

$60 (combined IN & OON)None100%100%50%50%50%

Pediatric Dental PPOPrime$60 (combined IN & OON)$1,000100%100%50%50%50%


$60 (combined IN & OON)None100%100%50%50%50%

2. Benefits apply to prescriptions filled at participating pharmacies. Please see Health Plan & Formulary Comparison Guide for non-participating pharmacy benefits. 3. See plan specific COI for information on preventive services.4. Limited to 100 4-hour visits per year.

19

Services PPO C PPO D


Network Name Select PPO Select PPO


Calendar Year Deductible* $500 / $1,000 $1,000 / $2,000 $1,200 / $2,400 $2,400 / $4,800Out-of-Pocket Max Ind/Fam 1 $3,000 / $6,000 $6,000 / $12,000 $3,500 / $7,000 $7,000 / $14,000Lifetime Maximum Unlimited UnlimitedDr. Office Visits (PCP) $20 Copay (first 3 visits) – 80% 50% $20 Copay (ded waived) 50%Specialist Visit (SPC) $20 Copay (first 3 visits) – 80% 50% $40 Copay (ded waived) 50%Laboratory 80% 50% 80% 50%X-Ray 80% 50% 80% 50%MRI, CT and PET 80% 50% (up to $800 per test) 80% 50% (up to $800 per test)Hospital Services –In-Patient

$500 Copay – 80% 50% (up to $650 per day) 80% 50% (up to $650 per day)


$200 Copay – 80% $200 Copay – 80% $200 Copay – 80% $200 Copay – 80%

Urgent Care 80% 50% $40 Copay (ded waived) 50%Hospital Services –Out-PatientSurgical FacilityAmbulatory Surgery Center

$250 Copay – 80%$250 Copay – 80%

50% (up to $380 per admit)50% (up to $380 per admit)

80%80%

50% (up to $380 per admit)50% (up to $380 per admit)

Hospital Pre-Authorization Required Required2nd Surgical Opinion $20 Copay (ded waived) 50% $40 Copay (ded waived) 50%Ambulance Services (per trip) 80% 80% 80% 80%Rx BenefitsGenericFormulary BrandNon-Formulary Brand

$15 Copay 2

$35 Copay 2

$70 Copay 2


$250 / $500 Ded – $35 Copay 2

$250 / $500 Ded – $70 Copay 2


$20 Copay (first 3 visits) – 80% 50% (up to $25 per visit) $20 Copay (ded waived) 50% (up to $25 per visit)

Acupuncture $20 Copay (first 3 visits) – 80% 50% $20 Copay (ded waived) 50%Physical, Occupational, Speech Therapy




* All services are subject to the deductible unless otherwise stated. Under a family contract, when an insured satisfies the individual deductible amount, no further de-ductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.


20


Services PPO C PPO D


Network Name Select PPO Select PPO






80% 4 50% (up to $75 per visit) 4 $20 Copay (ded waived) 4 50% (up to $75 per visit) 4

Skilled Nursing FacilityPer Disability (Max 100 days per year)

$500 Copay – 80% 50% (up to $150 per day) 80% 50% (up to $150 per day)

Hospice 100% 50% 100% 50%

Durable MedicalEquipment (Covered when medically necessary as determined by HCSP)

80% 50% 80% 50%


$500 Copay – 80%$20 Copay (first 3 visits) – 80%

50% (up to $650 per day)50%

80%$20 Copay (ded waived)

50% (up to $650 per day)50%

Drug/Substance AbuseIn-Patient (Detox Only) $500 Copay – 80% 50% (up to $650 per day) 80% 50% (up to $650 per day)




Frames




Anthem Vision




Anthem Vision



Pediatric Dental PPOPrime$60 (combined IN & OON)$1,000100%

100%50%50%

50%


$60 (combined IN & OON)None100%

100%50%50%

50%


100%50%50%

50%



100%50%50%

50%


21

Services PPO A

Participating Health Plans Health Net

Network Name Full

Metal Tier GoldIn-Network Out-of-Network

Calendar Year Deductible* None None

Out-of-Pocket Max Ind/Fam $6,350 / $12,700 2, 9 $12,700 / $25,400 2, 9

Lifetime Maximum (PCP) Unlimited

Dr. Office Visits (SPC) $30 Copay 50%

Specialist Visit $50 Copay 50%

Laboratory $30 Copay 50%

X-Ray $50 Copay 50%

MRI, CT and PET 80% 50%

Hospital Services –In-Patient

80% 50%


Emergency Room (copay waived if admitted)


Urgent Care $60 Copay 50%

Hospital Services –Out-PatientSurgical FacilityAmbulatory Surgery Center

80%80%

50%50%

Hospital Pre-Authorization Required or an additional $250 copay per day applies (does not apply to OOPM)

2nd Surgical Opinion $50 Copay 50%

Ambulance Services (per trip) $250 Copay $250 Copay


$19 Copay 4, 7, 8

$50 Copay 4, 7, 8

$70 Copay 4, 7, 8




Preventive/Wellness Services 3 100% Not Covered

Chronic Disease Management $50 Copay 50%

Chiropractic (20 visits max per year)

Not Covered


22


Services PPO A


Network Name Full

Metal Tier GoldIn-Network Out-of-Network

Acupuncture $30 Copay 1 Not CoveredPhysical, Occupational, Speech Therapy

$30 Copay Not Covered


$30 Copay Not Covered


80% 50%


80% (no limit) 50% (no limit)

Hospice 100% 50%Durable MedicalEquipment (Covered when medicallynecessary as determined by HCSP)

80% Not Covered


80%$30 Copay

50%50%

Drug/Substance AbuseIn-Patient (Detox Only) 80% 50%

Infertility Evaluation and Treatment Not CoveredPediatric VisionCarrierNetworkExamContact LensesFramesMaximum Allowance per year

EyeMed 5


EyeMed 5

Not CoveredNot CoveredNot CoveredNot Covered

Pediatric DentalCarrier NetworkDeductible

Out-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)


Dental Benefit Providers$60 / $120 (applies to all services)Combined with Medical100%100%50%50%50%


$60 / $120 (applies to all services)Combined with Medical100%100%50%50%50%

* All services are subject to the deductible unless otherwise stated.1. Must be medically necessary. 2. Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers.3. See plan specific COI for information on preventive services.4. The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary.5. Pediatric dental and vision are included on all plans.6. The pediatric dental benefits are provided by Health Net and administered by Dental Benefit Providers of California, Inc. (DBP). DBP is a California licensed specialized dental plan and is not affiliated with Health Net. Additional pediatric dental benefits are covered. See the Policy for details.7. Benefits apply to prescriptions filled at participating

pharmacies. Please see Health Plan & Formulary Comparison Guide for non-participating pharmacy benefits.

8. See plan specific COI for information regarding preventive drugs and women’s contraceptives.9. Under a family contract, an insured can satisfy their

individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum.

23



Network Name HMO Deductible Basic HMO Select HMO

Metal Tier Silver Silver Silver

Calendar Year Deductible* $2,000 / $4,000 4

(combined Med/Pediatric dental)$2,000 / $4,000 4

(combined Med/Pediatric dental)$1,850 / $3,700 4



Dr. Office Visits (PCP) $40 Copay (ded waived) $40 Copay (ded waived) $50 Copay (ded waived)

Specialist Visit (SPC) $60 Copay (ded waived) $60 Copay (ded waived) $70 Copay (ded waived)

Laboratory $60 Copay (ded waived) $60 Copay (ded waived) 100% (ded waived)

X-Ray $60 Copay (ded waived) $60 Copay (ded waived) 100% (ded waived)

MRI, CT and PET $500 Copay (ded waived) $500 Copay (ded waived) $150 Copay per test (ded waived)




$300 Copay $300 Copay $200 Copay – 70%

Urgent Care $50 Copay (ded waived) $50 Copay (ded waived) $70 Copay (ded waived)




70%70%


2nd Surgical Opinion $60 Copay (ded waived) $60 Copay (ded waived) $70 Copay (ded waived)



$20 Copay (overall ded waived) 2


50% up to $500 (overall ded waived) 2



50% up to $500 (overall ded waived) 2

$15 Copay (ded waived) $150 / $300 Ded – $35 Copay$150 / $300 Ded – $70 Copay

Oral Contraceptives 100% (generic only) 100% (generic only) 100%



Preventive/Wellness Services 3 100% (ded waived) 100% (ded waived) 100% (ded waived)

Chronic Disease Management Covered as any Illness Covered as any Illness $50 Copay (ded waived)

Chiropractic (20 visits max per year) $15 Copay (ded waived) $15 Copay (ded waived) $50 Copay (ded waived)

Acupuncture $15 Copay (ded waived) 1

12 visits max per year$15 Copay (ded waived) 1

12 visits max per year$50 Copay (ded waived)


$60 Copay (ded waived) $60 Copay (ded waived) $50 Copay (ded waived)




$40 Copay $40 Copay $50 Copay (ded waived) 6

SilverBenefit Summaries HMO

24



Network Name HMO Deductible Basic HMO Select HMO

Metal Tier Silver Silver SilverSkilled Nursing Facility PerDisability (Max 100 days per year)

$500 Copay per day – 3 days max $500 Copay per day – 3 days max 70%

Hospice 100% 100% 100%


80% 80% 70%






Infertility Evaluation and Treatment See Plan Specific EOC See Plan Specific EOC Not Covered


EyeMedEyeMed$60 Copay (ded waived)100% (Pref. Provider)100% (Pref. Provider)1 per calendar year

EyeMedEyeMed$60 Copay (ded waived)100% (Pref. Provider)100% (Pref. Provider)1 per calendar year

Anthem VisionBlue View Vision100% (ded waived)1 pair per calendar year1 pair per calendar year (ded waived)1 per calendar year


AetnaPPONone$1,000 / $2,000100%100%70%50%50%

AetnaPPONone$1,000 / $2,000100%100%70%50%50%


SilverBenefit Summaries (cont.)HMO

* All services are subject to the deductible unless otherwise stated.1. Unlimited visits for treatment of nausea or as part of a comprehensive pain management program and for anesthesia.2. Pharmacy tiers are Tier 1: Preferred Generic, Tier 2: Preferred Brand, Tier 3: Non-Preferred.3. See plan specific EOC for information on preventive services.4. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that

calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.5. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the

individual maximum copayment limit toward the family maximum.6. Limited to 100 4-hour visits per year.

25

Services EPO A HMO A†

Participating Health Plans Anthem Blue Cross Kaiser Permanente

Network Name Prudent Buyer - Small Group Full

Metal Tier Silver Silver

Calendar Year Deductible* $2,000 / $4,000 5 $1,500 / $3,000

Out-of-Pocket Max Ind/Fam $5,000 / $10,000 6 $6,350 / $12,700


Dr. Office Visits (PCP) $50 Copay (first 3 visits) – 70% 80%

Specialist Visit (SPC) $50 Copay (first 3 visits) – 70% 80%

Laboratory 70% 80%

X-Ray 70% 80%

MRI, CT and PET 70% 80% per procedure

Hospital Services – In-Patient $750 Copay – 70% 80%



$250 Copay – 70% 80%

Urgent Care 70% 80%


$250 Copay – 70%$250 Copay – 70%

80%80%

Hospital Pre-Authorization Required Required

2nd Surgical Opinion $50 Copay (first 3 visits) – 70% 80%

Ambulance Services (per trip) 70% 80%


$15 Copay (overall ded waived)$35 Copay (overall ded waived)$70 Copay (overall ded waived)

80% 80%80% (prior approval)

Oral Contraceptives 100% 100%



Preventive/Wellness Services 4 100% (ded waived) 100% (ded waived)

Chronic Disease Management 70% 80%

Chiropractic (20 visits max per year) $50 Copay (first 3 visits) – 70% Not Covered

Acupuncture $50 Copay (first 3 visits) – 70% 80%


$50 Copay (first 3 visits) – 70% 80%

SilverBenefit Summaries HMO & EPO

HSA Qualified

26

Services EPO A HMO A†

Participating Health Plans Anthem Blue Cross Kaiser Permanente

Network Name Prudent Buyer - Small Group Full

Metal Tier Silver SilverRehabilitative & HabilitativeServices and Devices

$50 Copay (first 3 visits) – 70% 80%


70% 7 100% 1

Skilled Nursing Facility PerDisability (Max 100 days per year)

$750 Copay – 70% 80%

Hospice 100% 100%


70% 80%


$750 Copay – 70% $50 Copay (first 3 visits) – 70%

80%80%

Drug/Substance AbuseIn-Patient (Detox Only) $750 Copay – 70% 80%

Infertility Evaluation and Treatment Not Covered Not Covered



Kaiser PermanenteKaiser Permanente100% (ded waived)1 pair per calendar year1 pair per calendar year (ded waived)None



Delta DentalDeltaCare USANone$1,000$20 Copay100% (ded waived)$95 Copay 2

$365 Copay 3

$1,000 Copay

SilverBenefit Summaries (cont.)

† HSA Qualified High Deductible Plan

* All services are subject to the deductible unless otherwise stated.1. Home Health Care visit part-time/intermittent coverage (2 hour(s) maximum per visit(s), 3 visit(s) maximum per day(s), 100 visit(s) maximum per

calendar year).2. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay

charged for procedures in this category cannot exceed the stated amount.3. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay

charged for procedures in this category cannot exceed the stated amount.4. See plan specific EOC for information on preventive services.5. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder

of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.6. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than

the individual maximum copayment limit toward the family maximum.7. Limited to 100 4-hour visits per year.

HMO & EPO

HSA Qualified

27

Services HMO B HMO C HMO A


Network Name Full Full Premier

Metal Tier Silver Silver Silver

Calendar Year Deductible* $1,000 / $2,000 6 $1,500 / $3,000 6 $1,800 / $3,600 4

Out-of-Pocket Max Ind/Fam $6,350 / $12,700 7 $6,350 / $12,700 7 $6,000 / $12,000 4


Dr. Office Visits (PCP) $40 Copay (ded waived) $45 Copay (ded waived) $30 Copay (ded waived)

Specialist Visit (SPC) $40 Copay (ded waived) $65 Copay (ded waived) $60 Copay (ded waived)

Laboratory $30 Copay (ded waived) $45 Copay (ded waived) $30 Copay

X-Ray $40 Copay (ded waived) $65 Copay (ded waived) $60 Copay

MRI, CT and PET 70% per procedure $250 Copay per procedure (ded waived) $250 Copay per procedure

Hospital Services – In-Patient 70% 80% $750 Copay per day



70% $250 Copay $250 Copay

Urgent Care $40 Copay (ded waived) $45 Copay (ded waived) $60 Copay (ded waived)


70%70%

80% (ded waived)80% (ded waived)

70%70%


2nd Surgical Opinion 70% 80% $60 Copay (ded waived)

Ambulance Services (per trip) 70% $250 Copay $250 Copay (ded waived)


$25 Copay (overall ded waived)$50 Copay (overall ded waived)$50 Copay (overall ded waived; prior approval)

$19 Copay (overall ded waived)$500 Ded – $50 Copay$500 Ded – $50 Copay (prior approval)


Oral Contraceptives 100% 100% 100% (if in formulary)




Chronic Disease Management $40 Copay 80% $60 Copay (ded waived)


Acupuncture $40 Copay (ded waived) $65 Copay (ded waived) $60 Copay (ded waived)






100% (ded waived) 1 100% (ded waived) 1 $60 Copay (ded waived)(100 days per year)


28

Services HMO B HMO C HMO A


Network Name Full Full Premier

Metal Tier Silver Silver SilverSkilled Nursing Facility PerDisability (Max 100 days per year)

70% 80% $200 Copay per day

Hospice 100% (ded waived) 100% (ded waived) 100% (ded waived)


70% (ded waived) 80% (ded waived) 50%




$750 Copay per day$60 Copay (ded waived)

Drug/Substance AbuseIn-Patient (Detox Only) 70% 80% $750 Copay per day

Infertility Evaluation and Treatment Not Covered Not Covered 50% of allowed charges




None


None




$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay




5. See plan specific EOC for information on preventive services.6. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that

calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.7. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the

individual maximum copayment limit toward the family maximum.

29



Network Name Performance Full


Calendar Year Deductible* $1,800 / $3,600 8 $2,000 / $4,000 1

Out-of-Pocket Max Ind/Fam $6,250 / $12,500 8 $6,350 / $12,700 2


Dr. Office Visits (PCP) $35 Copay (ded waived) $50 Copay (ded waived)

Specialist Visit (SPC) $70 Copay (ded waived) $50 Copay (ded waived)

Laboratory $15 Copay $50 Copay (ded waived)

X-Ray $30 Copay $50 Copay (ded waived)

MRI, CT and PET $300 Copay per procedure $250 Copay per test (ded waived)

Hospital Services – In-Patient 70% 80% 1,3

In-Patient Physician Fees 70% 100% (ded waived)


70% $250 Copay (ded waived)

Urgent Care $70 Copay (ded waived) $100 Copay (ded waived)


70%70%

80% 1,3

80% 1,3

Hospital Pre-Authorization Required Not Required

2nd Surgical Opinion $70 Copay (ded waived) $50 Copay (ded waived)

Ambulance Services (per trip) 70% (ded waived) 100% (ded waived)



$20 Copay (overall ded waived)$40 Copay (overall ded waived)$60 Copay (overall ded waived)

Oral Contraceptives 100% (if in formulary) 100%



Preventive/Wellness Services 9 100% (ded waived) 100% (ded waived) 4

Chronic Disease Management $70 Copay (ded waived) Covered as any Illness

Chiropractic (20 visits max per year) Not Covered Not Covered

Acupuncture $70 Copay (ded waived) $15 Copay (ded waived)


$50 Copay (ded waived) $50 Copay (ded waived)


$50 Copay (ded waived) $50 Copay (ded waived)


$70 Copay (ded waived)(100 days per year)

100% (ded waived)


30



Network Name Performance Full

Metal Tier Silver SilverSkilled Nursing Facility PerDisability (Max 100 days per year)

70% 80% 1,3

Hospice 100% (ded waived) 100% (ded waived)


50% 80% (ded waived) 1,3,5



80% 1,3

$50 Copay (ded waived)

Drug/Substance AbuseIn-Patient (Detox Only) 70% 80% 1,3

Infertility Evaluation and Treatment 50% of allowed charges Not Covered



VSPVSP100%1 pair In lieu of eyeglasses100% (Pediatric Exchangecollection only)None

MES VisionFull100%100%100%

1 per calendar year



$365 Copay 7

$1,000 Copay

Access DentalFullNone$1,000 / $2,000$20 Copay100%$95 Copay 6

$365 Copay 7

$1,000 Copay


* All services are subject to the deductible unless otherwise stated.1. Medical or prescription services may be subject to a deductible. The member must pay for these services when services are

rendered until the deductible is met in that calendar year. Charges under the deductible are based on WHA’s contracted rates with the provider of service.

2. The annual out-of-pocket maximum is the total amount the member must pay for certain services in a calendar year.3. Percentage copayment amounts are based on WHA’s contracted rates with the provider of service.4. There may be an office visit copay if the primary purpose of a visit is not preventive or other services are provided. 5. See copayment summary for applicable prosthetic/orthotic device copayment amount.6. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the

plan’s average copay charged for procedures in this category cannot exceed the stated amount.7. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the

plan’s average copay charged for procedures in this category cannot exceed the stated amount.8. Individuals enrolled in a family plan will reach the annual deductible or out-of-pocket maximum if the member meets the individual

deductible or out-of-pocket maximum amount or any combination of enrolled family members meets the family deductible or out-of-pocket maximum amount, whichever comes first. Amounts paid toward the deductible apply toward the out-of-pocket maximum.


31




Metal Tier Silver SilverIn-Network Out-of-Network In-Network Out-of-Network

Calendar Year Deductible* $1,250 / $2,500 $2,500 / $5,000 $1,500 / $3,000 $3,000 / $6,000Out-of-Pocket Max Ind/Fam 1 $5,500 / $11,000 $11,000 / $22,000 $4,250 / $8,500 $8,500 / $17,000Lifetime Maximum Unlimited UnlimitedDr. Office Visits (PCP) $25 Copay (first 3 visits) – 60% 50% $35 Copay (first 3 visits) – 70% 50%Specialist Visit (SPC) $25 Copay (first 3 visits) – 60% 50% $35 Copay (first 3 visits) – 70% 50%Laboratory 60% 50% 70% 50%X-Ray 60% 50% 70% 50%MRI, CT and PET 60% 50% (up to $800 per test) 70% 50% (up to $800 per test)Hospital Services –In-Patient

Tier 1: 60%Tier 2: $500 Copay – 60%

50% (up to $650 per day) $500 Copay – 70% 50% (up to $650 per day)


60% 60% $250 Copay – 70% $250 Copay – 70%

Urgent Care 60% 50% 70% 50%Hospital Services –Out-PatientSurgical Facility

Ambulatory Surgery Center

Tier 1: 60%Tier 2: $250 Copay – 60%Tier 1: 60%Tier 2: $250 Copay – 60%



$250 Copay – 70%

$250 Copay – 70%



Hospital Pre-Authorization Required Required2nd Surgical Opinion $25 Copay (ded waived) 50% $35 Copay (ded waived) 50%Ambulance Services (per trip) 60% 60% 70% 70%Rx BenefitsGenericFormulary BrandNon-Formulary Brand


$250 / $500 Ded – $35 Copay 2

$250 / $500 Ded – $70 Copay 2


$250 / $500 Ded – $35 Copay 2

$250 / $500 Ded – $70 Copay 2


$25 Copay (first 3 visits) – 60% 50% (up to $25 per visit) $35 Copay (first 3 visits) – 70% 50% (up to $25 per visit)

Acupuncture $25 Copay (first 3 visits) – 60% 50% $35 Copay (first 3 visits) – 70% 50%Physical, Occupational, Speech Therapy



SilverBenefit Summaries PPO

* All services are subject to the deductible unless otherwise stated. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.


32

SilverBenefit Summaries (cont.)PPO





In-Network Out-of-Network In-Network Out-of-NetworkRehabilitative & Habilitative Services and Devices




60% 4 50% (up to $75 per visit) 4 70% 4 50% (up to $75 per visit) 4

Skilled Nursing FacilityPer Disability(Max 100 days per year)

Tier 1: 60%Tier 2: $500 Copay – 60%


Hospice 100% 50% 100% 50%Durable MedicalEquipment (Covered when medically necessary as determined by HCSP)

60% 50% 70% 50%

Mental HealthIn-Patient

Out-Patient

Tier 1: 60%Tier 2: $500 Copay – 60%$25 Copay (first 3 visits) – 60%


50%

$500 Copay – 70%

$35 Copay (first 3 visits) – 70%


50%

Drug/Substance AbuseIn-Patient (Detox Only)

Tier 1: 60%Tier 2: $500 Copay – 60%





Frames




Anthem Vision




Anthem Vision




100%50%50%

50%



100%50%50%

50%


100%50%50%

50%



100%50%50%

50%


33

Services PPO A


Network Name Full

Metal Tier SilverIn-Network Out-of-Network

Calendar Year Deductible* $1,500 / $3,000 10 $3,000 / $6,000 10


Lifetime Maximum Unlimited

Dr. Office Visits (PCP) $45 Copay (ded waived) 50%

Specialist Visit (SPC) $65 Copay (ded waived) 50%

Laboratory $45 Copay (ded waived) 50%

X-Ray $65 Copay (ded waived) 50%

MRI, CT and PET 80% 50%

Hospital Services – In-Patient 80% 50%

In-Patient Physician Fees 80% (ded waived) 50%



Urgent Care $90 Copay (ded waived) 50%


80% (ded waived)80% (ded waived)

50%50%


2nd Surgical Opinion $65 Copay (ded waived) 50%

Ambulance Services (per trip) $250 Copay $250 Copay


$19 Copay (ded waived) 4, 7, 8

$500 / $1,000 Ded – $50 Copay 4, 7, 8, 9

$500 / $1,000 Ded – $70 Copay 4, 7, 8, 9




Preventive/Wellness Services 3 100% (ded waived) Not Covered

Chronic Disease Management $65 Copay (ded waived) 50%

Chiropractic (20 visits max per year) Not Covered

Acupuncture $45 Copay (ded waived) 1 Not Covered

Physical, Occupational, Speech Therapy

$45 Copay (ded waived) Not Covered

SilverBenefit Summaries PPO

34

SilverBenefit Summaries (cont.)PPO

Services PPO A


Network Name Full

Metal Tier SilverIn-Network Out-of-Network


$45 Copay (ded waived) Not Covered


80% (ded waived) 50%



Hospice 100% (ded waived) 50%Durable MedicalEquipment (Covered when medically necessary as determined by HCSP)

80% (ded waived) Not Covered



50%50%

Drug/Substance AbuseIn-Patient (Detox Only) 80% 50%Infertility Evaluation and Treatment

Not Covered


EyeMed 5


EyeMed 5





Dental Benefit Providers$60 / $120 (applies to all services)Combined with Medical100%

100%50%50%

50%


$60 / $120 (applies to all services)Combined with Medical100%

100%50%50%

50%

* All services are subject to the deductible unless otherwise stated.1. Must be medically necessary.2. Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers.3. See plan specific COI for information on preventive services.4. The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary.5. Pediatric dental and vision are included on all plans.6. The pediatric dental benefits are provided by Health Net and administered by Dental Benefit Providers of California, Inc. (DBP). DBP is a California licensed specialized dental plan and is not affiliated with Health Net. Additional pediatric dental benefits are covered. See the Policy for details.7. Benefits apply to prescriptions filled at participating pharmacies.

Please see Health Plan & Formulary Comparison Guide for non-participating pharmacy benefits.

8. See plan specific COI for information regarding preventive drugs and women’s contraceptives.

9. The brand-name prescription drug deductible (per member, per calendar year) must be paid before Health Net begins to pay for brand-name prescription drugs.

10. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.


35

Services HMO A HMO A† HMO B

Participating Health Plans Aetna Kaiser Permanente Kaiser Permanente

Network Name HMO Deductible Full Full

Metal Tier Bronze Bronze Bronze


(combined Med/Pediatric dental) $3,500 / $7,000 8 $5,000 / $10,000 8



Dr. Office Visits (PCP) $50 Copay (ded waived) $30 Copay $60 Copay 7

Specialist Visit (SPC) $75 Copay (ded waived) $30 Copay $70 Copay

Laboratory $50 Copay (ded waived) $30 Copay 70%

X-Ray $75 Copay (ded waived) $30 Copay 70%

MRI, CT and PET $500 Copay (ded waived) 70% per procedure 70% per procedure

Hospital Services – In-Patient 50% 70% 70%



50% 70% $300 Copay

Urgent Care $50 Copay (ded waived) $30 Copay $60 Copay 7


50%50%

70%70%

70%70%


2nd Surgical Opinion $75 Copay (ded waived) $30 Copay $60 Copay

Ambulance Services (per trip) $150 Copay 70% $300 Copay



$250 Ded – $75 Copay 5

$250 Ded – 50% up to $500 5



Oral Contraceptives 100% (generic only) 100% 100%




Chronic Disease Management Covered as any Illness $30 Copay $60 Copay

Chiropractic (20 visits max per year) $15 Copay (ded waived) Not Covered Not Covered

Acupuncture $15 Copay (ded waived) 1

12 visits max per year$30 Copay $70 Copay






$50 Copay 100% 2 100% 2

BronzeBenefit Summaries HMO

HSA Qualified

36

Services HMO A HMO A† HMO B

Participating Health Plans Aetna Kaiser Permanente Kaiser Permanente

Network Name HMO Deductible Full Full

Metal Tier Bronze Bronze BronzeSkilled Nursing Facility PerDisability (Max 100 days per year)

50% 70% 70%

Hospice 100% 100% 100%


50% 70% 70%



70%$30 Copay

70%$60 Copay 7

Drug/Substance AbuseIn-Patient (Detox Only) 50% 70% 70%

Infertility Evaluation and Treatment See Plan Specific EOC Not Covered Not Covered


EyeMedEyeMed$75 Copay (ded waived) 100% (Pref. Provider)100% (Pref. Provider)1 per calendar year




AetnaPPONone$1,000 / $2,000100%100%70%50%50%


$365 Copay 4

$1,000 Copay


$365 Copay 4

$1,000 Copay

BronzeBenefit Summaries (cont.)HMO

HSA Qualified


* All services are subject to the deductible unless otherwise stated.1. Unlimited visits for treatment of nausea or as part of a comprehensive pain management program and for anesthesia.2. Home Health Care visit part-time/intermittent coverage (2 hour(s) maximum per visit(s), 3 visit(s) maximum per day(s), 100 visit(s) maximum per calendar year).3. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for

procedures in this category cannot exceed the stated amount.4. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay charged for

procedures in this category cannot exceed the stated amount.5. Pharmacy tiers are Tier 1: Preferred Generic, Tier 2: Preferred Brand, Tier 3: Non-Preferred.6. See plan specific EOC for information on preventive services.7. Deductible is waived for first three visits (combined for primary care, urgent care, and individual mental/behavioral health and substance use disorder services).8. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that

calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.9. Under a family contract, an insured can satisfy their individual out-of-pocket maximum, however, an insured may not contribute an amount greater than the individual

maximum copayment limit toward the family maximum.

37

Services HMO C† HMO A HMO B†




Calendar Year Deductible* $4,500 / $9,000 $2,000 / $4,000 4

(combined Med/Rx ded)$3,750 / $7,500 4

(combined Med/Rx ded)

Out-of-Pocket Max Ind/Fam $6,350 / $12,700 $6,350 / $12,700 4 $6,350 / $12,700 4


Dr. Office Visits (PCP) 60% $60 Copay 60%

Specialist Visit (SPC) 60% $120 Copay 60%

Laboratory 60% $60 Copay 60%

X-Ray 60% $120 Copay 60%

MRI, CT and PET 60% per procedure $400 Copay per procedure 60%

Hospital Services – In-Patient 60% $1,500 Copay per day – 3 days max 60%



60% $500 Copay 60%

Urgent Care 60% $120 Copay 60%


60%60%

60%60%

60%60%


2nd Surgical Opinion 60% $120 Copay 60%

Ambulance Services (per trip) 60% $350 Copay 60%


60%60%60% (prior approval)

$19 Copay (ded waived)$60 Copay (combined Med/Rx ded)$120 Copay (combined Med/Rx ded)

60% (combined Med/Rx ded)60% (combined Med/Rx ded)60% (combined Med/Rx ded)

Oral Contraceptives 100% 100% (if in formulary) 100% (if in formulary)




Chronic Disease Management 60% $120 Copay 60%


Acupuncture 60% $120 Copay 60%


60% $50 Copay 60%


60% $50 Copay 60%


100% 1 $120 Copay(100 days per year)

60%(100 days per year)

BronzeBenefit Summaries HMO

HSA QualifiedHSA Qualified

38

Services HMO C† HMO A HMO B†




Skilled Nursing Facility PerDisability (Max 100 days per year)

60% $200 Copay per day 60%

Hospice 100% 100% 100%


60% 50% 50%


60%60%

$1,500 Copay per day – 3 days max$120 Copay

60%60%

Drug/Substance AbuseIn-Patient (Detox Only) 60% $1,500 Copay per day – 3 days max 60%

Infertility Evaluation and Treatment Not Covered 50% of allowed charges 50% of allowed charges







$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay


$365 Copay 3

$1,000 Copay

BronzeBenefit Summaries (cont.)HMO




5. See plan specific EOC information on preventive services.

HSA QualifiedHSA Qualified

39

Services HMO A† EPO A

Participating Health Plans Western Health Advantage Anthem Blue Cross

Network Name Full Prudent Buyer - Small Group

Metal Tier Bronze BronzeCalendar Year Deductible* $3,500 / $7,000 1, 7 $5,600 / $11,200 7

Out-of-Pocket Max Ind/Fam 8 $6,350 / $12,700 2 $6,350 / $12,700


Dr. Office Visits (PCP) 70% 1,4 $65 Copay (first 3 visits) – 60%

Specialist Visit (SPC) 70% 1,4 $65 Copay (first 3 visits) – 60%

Laboratory 70% 1,4 60%

X-Ray 70% 1,4 60%

MRI, CT and PET 70% 1,4 60%

Hospital Services – In-Patient 70% 1,4 $1,000 Copay – 60%

In-Patient Physician Fees 70% 1,4 60%

Emergency Room (copay waived if admitted) 70% 1,4 $400 Copay – 60%

Urgent Care 70% 1,4 60%


70% 1,4

70% 1,4

$500 Copay – 60%$500 Copay – 60%

Hospital Pre-Authorization Not Required Required

2nd Surgical Opinion 70% 1,4 $65 Copay (first 3 visits) – 60%

Ambulance Services (per trip) 70% 1,4 60%


70% 1,4

70% 1,4

70% 1,4

$19 Copay (ded waived)$750 / $1,500 Ded – $50 Copay$750 / $1,500 Ded – $90 Copay

Oral Contraceptives 100% 100%



Preventive/Wellness Services 6 100% (ded waived) 3 100% (ded waived)

Chronic Disease Management Covered as any Illness 60%

Chiropractic (20 visits max per year) Not Covered $65 Copay (first 3 visits) – 60%

Acupuncture $15 Copay $65 Copay (first 3 visits) – 60%

Physical, Occupational, Speech Therapy 70% 1,4 $65 Copay (first 3 visits) – 60%


70% 1,4 $65 Copay (first 3 visits) – 60%

Home Health Care (Max 100 visits per year) 70% 1,4 60% 11

BronzeBenefit Summaries HMO & EPO

HSA Qualified

40

Services HMO A† EPO A

Participating Health Plans Western Health Advantage Anthem Blue Cross

Network Name Full Prudent Buyer - Small Group

Metal Tier Bronze BronzeSkilled Nursing Facility Per Disability (Max 100 days per year)

70% 1,4 $1,000 Copay – 60%

Hospice 100% 1,4 100%


70% 1,4,5 60%


70% 1,4

70% 1,4

$1,000 Copay – 60%$65 Copay (first 3 visits) – 60%

Drug/Substance AbuseIn-Patient (Detox Only) 70% 1,4 $1,000 Copay – 60%

Infertility Evaluation and Treatment Not Covered Not Covered


MES VisionFull100% (ded waived)100%100% (ded waived)1 per calendar year



Access DentalFullNone$1,000 / $2,000$20 Copay100% (ded waived)$95 Copay 9

$365 Copay 10

$1,000 Copay


BronzeBenefit Summaries (cont.)


* All services are subject to the deductible unless otherwise stated.1. Medical or prescription services may be subject to a deductible. The member must pay for these services when services are rendered until the

deductible is met in that calendar year. Charges under the deductible are based on WHA’s contracted rates with the provider of service.2. The annual out-of-pocket maximum is the total amount the member must pay for certain services in a calendar year.3. There may be an office visit copay if the primary purpose of a visit is not preventive or other services are provided.4. Percentage copayment amounts are based on WHA’s contracted rates with the provider of service.5. See copayment summary for applicable prosthetic/orthotic device copayment amount.6. See plan specific EOC for information on preventive services.7. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder

of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.8. Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than

the individual maximum copayment limit toward the family maximum.9. DHMO Basic Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay

charged for procedures in this category cannot exceed the stated amount.10. DHMO Major Services copayments vary by procedure within this category. Using a statistically significant set of claims data, the plan’s average copay

charged for procedures in this category cannot exceed the stated amount.11. Limited to 100 4-hour visits per year.

HMO & EPO

HSA Qualified

41

Services PPO A


Network Name Full

Metal Tier BronzeIn-Network Out-of-Network


(combined Med/Rx ded)$10,000 / $20,000 10

(combined Med/Rx ded)


Lifetime Maximum UnlimitedDr. Office Visits (PCP) $60 Copay 9 50%Specialist Visit (SPC) $70 Copay 50%Laboratory 70% 50%X-Ray 70% 50%MRI, CT and PET 70% 50%Hospital Services –In-Patient

70% 50%

In-Patient Physician Fees 70% 50%Emergency Room(copay waived if admitted)


Urgent Care $120 Copay 9 50%Hospital Services –Out-PatientSurgical FacilityAmbulatory Surgery Center

70%70%

50%50%


2nd Surgical Opinion $70 Copay 50%Ambulance Services (per trip) $300 Copay $300 CopayRx BenefitsGenericFormulary BrandNon-Formulary Brand

$19 Copay (combined Med/Rx ded) 4, 7, 8

$50 Copay (combined Med/Rx ded) 4, 7, 8, 12

$75 Copay (combined Med/Rx ded) 4, 7, 8, 12

Oral Contraceptives 100%Pre-Existing Conditions CoveredMaternity andNewborn Care

Covered as any Illness 9

Preventive/Wellness Services 3 100% (ded waived) Not CoveredChronic Disease Management $70 Copay 50%Chiropractic(20 visits max per year)

Not Covered

Acupuncture $60 Copay 1 Not CoveredPhysical, Occupational, Speech Therapy

70% Not Covered

BronzeBenefit Summaries PPO

42

BronzeBenefit Summaries (cont.)PPO

Services PPO A


Network Name Full

Metal Tier BronzeIn-Network Out-of-Network


70% Not Covered


70% 50%



Hospice 100% 50%Durable MedicalEquipment (Covered when medically necessary as determined by HCSP)

70% Not Covered


70%$60 Copay 9

50%50%

Drug/Substance AbuseIn-Patient (Detox Only) 70% 50%Infertility Evaluation and Treatment

Not Covered


EyeMed 5


EyeMed 5





Dental Benefit Providers$60 / $120 (applies to all services)Combined with Medical100%

100%50%50%

50%


$60 / $120 (applies to all services)Combined with Medical100%

100%50%50%

50%

* All services are subject to the deductible unless otherwise stated.1. Must be medically necessary.2. Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers.3. See plan specific COI for information on

preventive services.4. The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary.5. Pediatric dental and vision are included on all plans.6. The pediatric dental benefits are provided by Health Net and administered by Dental Benefit Providers of California, Inc. (DBP). DBP is a California licensed specialized dental plan and is not affiliated with Health Net. Additional pediatric dental benefits are covered. See the Policy for details.7. Benefits apply to prescriptions filled at participating

pharmacies. Please see Health Plan & Formulary Comparison Guide for non-participating pharmacy benefits.

8. See plan specific COI for information regarding preventive drugs and women’s contraceptives.

9. Deductible is waived for first three visits (combined for primary care, urgent care, postnatal, outpatient mental health and substance abuse non-preventive visits are combined).

10. Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible.


12. The brand-name prescription drug deductible (per member, per calendar year) must be paid before Health Net begins to pay for brand-name prescription drugs.

43

Notes

THE SMALL GROUP

Private EXCHANGE

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