Forms & Brochures – Large Business Group Plans

• 2022 Enhanced Choice Medical Portfolio: 1/1/22 effective - English (PDF)
• 2022 Enhanced Choice Supplemental Portfolio: 1/1/22 effective - English (PDF)
• 2022 Starting Line-Up Medical Portfolio: 1/1/22 effective - English (PDF)
• 2022 Starting Line-Up Supplemental Portfolio: 1/1/22 effective - English (PDF)
• 2021 Enhanced Choice Medical Portfolio: 1/1/21 effective - English (PDF)
• 2021 Enhanced Choice Supplemental Portfolio: 1/1/21 effective - English (PDF)
• 2021 Starting Line-Up Medical Portfolio: 1/1/21 effective - English (PDF)
• 2021 Starting Line-Up Supplemental Portfolio: 1/1/21 effective - English (PDF)
• Large Group Portfolio Book – English (PDF)
• CanopyCare HMO - Broker Flyer – English (PDF)
• Enhanced Choice Solutions 2021 - Broker Flyer - English (PDF)
• Enhanced Choice Solutions 2022 - Broker Flyer - English (PDF)
• EOA Products Broker Brochure – English (PDF)
• EOA Deductible Plans Broker Flyer – English (PDF)
• ExcelCare Network Broker Flyer – English (PDF)

Presentation Folders

Note: For example only. Folders can be ordered on Step 2

• Generic Folder – English (PDF)
• Open Enrollment Folder – English (PDF)
• Open Enrollment Folder – En Español (Spanish) (PDF)

Open Enrollment Product flyers

To be used as inserts with the OE Folders, may not be used as stand-alone flyers.

• Open Enrollment Product flyer – HMO – English (PDF)
• Open Enrollment Product flyer – HMO – En Español (Spanish) (PDF)
• Open Enrollment Product flyer – PPO – English (PDF)
• Open Enrollment Product flyer – PPO – En Español (Spanish) (PDF)
• Open Enrollment Product flyer – POS – English (PDF)
• Open Enrollment Product flyer – POS – En Español (Spanish) (PDF)
• Open Enrollment Product flyer – EOA – English (PDF)
• Open Enrollment Product flyer – EOA – En Español (Spanish) (PDF)
• Open Enrollment Product flyer – SmartCare – English (PDF)
• Open Enrollment Product flyer – SmartCare – En Español (Spanish) (PDF)

2022 – Enrollment and Change Applications

• 2022 – Employee Enrollment and Change Form – English (PDF)
• 2022 – Employee Enrollment and Change Form – En Español (Spanish) (PDF)
• 2022 – Employee Enrollment and Change Form – 中文 (Chinese) (PDF)
• 2022 – Employee Enrollment and Change Form – 한국어 (Korean) (PDF)
• 2022 – Employee Enrollment and Change Form – Tiếng Việt (Vietnamese) (PDF)

Group Service Agreement/Policy Applications

• Group Size Attestation Form – English (PDF)
• Application for Group Service Agreement/Policy – English (PDF)
• Application for Group Term Life Insurance Policy Form – English (PDF)

Claims

• Commercial Medical Claim Form – English (PDF)
• Commercial Medical Claim Form – En Español (Spanish) (PDF)
• Commercial MHN Claim Form – English (PDF)
• Dental Claim Form – English (PDF)
• Vision Claim Form – English (PDF)
• Prescription Drug Claim Form – English (PDF)
• Prescription Drug Claim Form – En Español (Spanish) (PDF)

Transition of Care

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Prescription Transition form – English (PDF)
• Prescription Transition form – En Español (Spanish) (PDF)

Dental and Vision Add-On or Change Form

Dental and Vision Add-On or Change Form – English (PDF)

Health Net Life Insurance Forms

• Employee Enrollment and Change Form – English (PDF)
• Employee Enrollment and Change Form – En Español (Spanish) (PDF)
• Evidence of Insurability Life Form – English (PDF)
• Life Insurance Claim Form – English (PDF)
• Life Insurance Claim Form – En Español (Spanish) (PDF)
• Member Life Insurance Waiver of Premium Claim Form – English (PDF)

Broker and Employer Forms

HIPAA Disclosures

• Group Health Plan HIPAA Disclosure Forms – Disclosure Directive (DOCX)
• Group Health Plan HIPAA Disclosure Forms – Large Group Claims Data Request & Attestation – English (PDF)
• Authorization For Disclosure of PHI – English (PDF)
• Authorization For Disclosure of PHI – En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI – (Chinese) (PDF)
• Authorization For Disclosure of PHI – (Korean) (PDF)

Health Care Reform Materials

• Questions to Help Determine Grandfathered Plan Status (Employer) – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – En Español (Spanish) (PDF)

SmartCare

• SmartCare Broker Brochure – English (PDF)
• SmartCare Employer Flyer – English (PDF)

Support Tools

• Commercial Sales Guidelines – English (PDF)
• Top Reasons for Health Net: Employer version – English (PDF)
• Large Group Employer Guide – English (PDF)
• Health Net Financial Strength and Stability – English (PDF)
• Top Reasons for Health Net: Broker version – English (PDF)
• 2021/2022 Forrester and Newsweek Customer Service Award Announcement (Broker) – English (PDF)
• 2021/2022 Forrester and Newsweek Customer Service Award Announcement (Member) – English (PDF)
• Active&Fit Direct Member Flyer – English (PDF)
• Active&Fit Direct Member Flyer – En Español (Spanish) (PDF)
• Babylon Flyer – English (PDF)
• Babylon Flyer – En Español (Spanish) (PDF)
• Behavior Health / MHN Flyer (Custom) – English (PDF)
• Behavior Health / MHN Flyer (Static) – English (PDF)
• Children's Anxiety Flyer – English (PDF)
• ER vs. Urgent Care – English (PDF)
• ER vs. Urgent Care – En Español (Spanish) (PDF)
• HealthNet.com Flyer – English (PDF)
  HealthNet.com Flyer – En Español (Spanish) (PDF)
• HMO Flu Shot Flyer – English (PDF)
• HMO Flu Shot Flyer – En Español (Spanish) (PDF)
• Understanding the Continuity of Care Policy – English (PDF)
• ID Card Express Program – English (PDF)
• MinuteClinic Brochure – English (PDF)
• MinuteClinic Brochure – En Español (Spanish) (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – English (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – (Chinese) (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – Navajo (PDF)
• Uniform Glossary of Health Coverage and Medical Terms – (Korean) (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer, understand some of the most common language used in health insurance documents.

Health Net Beginnings

• Health Net Beginnings – English (PDF)
• Health Net Beginnings – En Español (Spanish) (PDF)

Online Support Tools

Group Administrator Registration Guide – English (PDF)

First Health National (Out-of-State) PPO

• First Health Physician Nomination Form – English (PDF)
• Broker First Health National PPO Network FAQ – English (PDF)
• Member First Health National PPO Network FAQ – English (PDF)

• Pharmacy Benefits Member Guide – English (PDF)
• Pharmacy Benefits Member Guide – En Español (Spanish) (PDF)
• Generic vs Brand-Name Drugs Information – English (PDF)
• Coverage of Blood Glucose Test Strips – For New Members – English (PDF)
• Take Medications the Right Way – English (PDF)
• Getting Started With Mail Order Pharmacy Kit – English (PDF)
• Getting Started With Mail Order Pharmacy Kit – En Español (Spanish) (PDF)

Salud HMO y Más Service Area ZIP Codes – English (PDF)

Broker/Employer

• Salud con Health Net Overview – English (PDF)
• Broker/Employer – Salud HMO y Más/Scripps Health Flyer – English (PDF)

Member

Salud HMO y Más Brochure – English/Spanish (PDF)

• Ancillary sell sheet – English (PDF)
• Broker Supplemental Benefit Multi-Bundling Flyer – English (PDF)

Dental Materials

• Dental Provider Search Flyer – English (PDF)
• Your Dental Website (member) – English (PDF)

Vision Materials

Effective 2/1/20 Sears Optical, JC Penney Optical and Stanton Optical will no longer be in the EyeMed network.

Vision Website (member) – English (PDF)

Health Net Life

Health Net Life Product Guide (Employer) – English (PDF)

These forms are customizable to allow for the addition of benefit level.

• Basic Life Insurance with AD&D – English (PDF)
• Basic Life Insurance with AD&D – En Español (Spanish) (PDF)
• Basic Life Insurance no AD&D – English (PDF)

• Decision Power^® Member Brochure – English (PDF)
• Decision Power^® Member Brochure – En Español (Spanish) (PDF)
• Health Coaching Program Flyer – English (PDF)
• Healthy Discounts Member Flyer – English (PDF)
• Healthy Discounts Member Flyer – En Español (Spanish) (PDF)
• myStrength Program Flyer – English (PDF)
• myStrength Program Flyer – En Español (Spanish) (PDF)
• Preventive Screening Guidelines – English (PDF)
• Preventive Screening Guidelines – En Español (Spanish) (PDF)
• Ready to Lose Weight? - English
• Ready to Lose Weight? - En Español (Spanish)
• Smoking and Tobacco Cessation – English (PDF)
• Smoking and Tobacco Cessation – En Español (Spanish) (PDF)
• Tips to Stop Smoking – English & Spanish (PDF)
• Wellness Tools – English (PDF)
• Wellness Tools – En Español (Spanish) (PDF)
• 2022 Wellness Webinar Flyer – English (PDF)

Promotional flyer and press releases for Health Net's new "Text4Baby" program. This new service provides the expectant mother with 3 free text messages a week, providing helpful information throughout her pregnancy and for baby's first year.

ShareCare

• ShareCare FAQs – English (PDF)
• ShareCare RealAge Program Overview – English (PDF)
• ShareCare RealAge Program FAQs – English (PDF)
• ShareCare Green Day Overview – English (PDF)
• ShareCare How to Link Trackers Guide – English (PDF)

Broker / Employer Materials

• Decision Power Employer/Broker Toolkit – English (PDF)
• Health Coaching Program Flyer – English (PDF)
• Healthy Discounts Member Flyer – English (PDF)
• Healthy Discounts Member Flyer – En Español (Spanish) (PDF)
• National Observances Calendar for Employers – English (PDF)
• Preventive Screening Guidelines – English (PDF)
• Preventive Screening Guidelines – En Español (Spanish) (PDF)
• 2022 Wellness Webinar Flyer – English (PDF)

Travel Guides

• HMO/POS Travel Guide – English (PDF)
• HMO/POS Travel Guide – En Español (Spanish) (PDF)

Claim forms can also be found under the Applications and Forms section on this page.

• PPO Travel Guide – English (PDF)
• PPO Travel Guide – En Español (Spanish) (PDF)

Claim forms can also be found under the Applications and Forms section on this page.

Additional Materials

• Understanding your Explanation of Benefits (EOB) – English/Spanish (PDF)
• Out-of-Pocket Maximum Notification – English (PDF)
• Understanding Your Billing Statement – English (PDF)

Are your clients looking for greater convenience, service and choice in consumer directed health care benefits? We have partnered with HealthEquity for HRA and HSA integration alongside our Large group products. A proven expert in financial arrangement integration and administration, HealthEquity offers easy-to-use tools and comprehensive resources. Our PPO high deductible health plans (HDHP's), can be offered alongside their integrated health savings account (HSA), while all of our PPO plans can be offered with their integrated health reimbursement account (HRA).

Learn more about HealthEquity HSA & HRA Plans on the HealthEquity website. Go to HealthEquity sales resource site.

• 2022 HSA-compatible PPO Member brochure – English (PDF)
• HSA Employer Flyer – English (PDF)

Full Network HMO

• Full Network HMO-HSM-10/250a ($1,500 / $3,000) - English (PDF)
• Full Network HMO-HSN-15/0 ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSO-15/250a ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSQ-20/20% ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSR-20/250a ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSU-30/20% ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSZ-40/20% ($2,500 / $7,500) - English (PDF)
• Full Network HMO-HSS-20/500a ($3,500 / $10,500) - English (PDF)
• Full Network HMO-HST-20/500d ($3,500 / $10,500) - English (PDF)
• Full Network HMO-HSV-30/30% ($3,500 / $10,500) - English (PDF)
• Full Network HMO-HSX-30/1000a ($3,500 / $10,500) - English (PDF)
• Full Network HMO-HT0-40/30% ($3,500 / $10,500) - English (PDF)
• Full Network HMO-HSW-30/250d ($4,500 / $9,000) - English (PDF)
• Full Network HMO-HT2-40/500d ($4,500 / $9,000) - English (PDF)
• Full Network HMO-HSK-0/1000d ($5,500 / $11,000) - English (PDF)
• Full Network HMO-HSY-35/30% ($5,500 / $11,000) - English (PDF)
• Full Network HMO-HT1-40/40% ($5,500 / $11,000) - English (PDF)
• Full Network HMO-HSL-10/30% ($6,500 / $13,000) - English (PDF)
• Full Network HMO-HSP-15/1500d ($6,500 / $13,000) - English (PDF)
• Full Network HMO-HT3-40/1500d ($6,500 / $13,000) - English (PDF)
• Full Network HMO-HT4-50/1500d ($6,500 / $13,000) - English (PDF)
• Full Network HMO-HT5-60/1500a ($8,700 / $17,400) - English (PDF)

ExcelCare HMO

• ExcelCare HMO-HVE-10/250a ($1,500 / $3,000) - English (PDF)
• ExcelCare HMO-HVF-15/250a ($2,500 / $7,500) - English (PDF)
• ExcelCare HMO-HVI-20/250a ($2,500 / $7,500) - English (PDF)
• ExcelCare HMO-HVH-20/20% ($2,500 / $7,500) - English (PDF)
• ExcelCare HMO-HVK-30/20% ($2,500 / $7,500) - English (PDF)
• ExcelCare HMO-HVJ-20/500a ($3,500 / $10,500) - English (PDF)
• ExcelCare HMO-HVL-30/30% ($3,500 / $10,500) - English (PDF)
• ExcelCare HMO-HVP-40/30% ($3,500 / $10,500) - English (PDF)
• ExcelCare HMO-HVN-30/1000a ($3,500 / $10,500) - English (PDF)
• ExcelCare HMO-HVM-30/250d ($4,500 / $9,000) - English (PDF)
• ExcelCare HMO-HVR-40/500d ($4,500 / $9,000) - English (PDF)
• ExcelCare HMO-HVC-0/1000d ($5,500 / $11,000) - English (PDF)
• ExcelCare HMO-HVO-35/30% ($5,500 / $11,000) - English (PDF)
• ExcelCare HMO-HVQ-40/40% ($5,500 / $11,000) - English (PDF)
• ExcelCare HMO-HVD-10/30% ($6,500 / $13,000) - English (PDF)
• ExcelCare HMO-HVG-15/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare HMO-HVS-40/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare HMO-HVT-50/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare HMO-HVU-60/1500a ($8,700 / $17,400) - English (PDF)

SmartCare HMO

• SmartCare HMO-HS4-10/250a ($1,500 / $3,000) - English (PDF)
• SmartCare HMO-HS5-15/250a ($2,500 / $7,500) - English (PDF)
• SmartCare HMO-HS7-20/20% ($2,500 / $7,500) - English (PDF)
• SmartCare HMO-HS9-30/20% ($2,500 / $7,500) - English (PDF)
• SmartCare HMO-HS8-20/500a ($3,500 / $10,500) - English (PDF)
• SmartCare HMO-HSB-30/30% ($3,500 / $10,500) - English (PDF)
• SmartCare HMO-HSC-30/250d ($4,500 / $9,000) - English (PDF)
• SmartCare HMO-HSF-40/500d ($4,500 / $9,000) - English (PDF)
• SmartCare HMO-HS2-0/1000d ($5,500 / $11,000) - English (PDF)
• SmartCare HMO-HSD-35/30% ($5,500 / $11,000) - English (PDF)
• SmartCare HMO-HSE-40/40% ($5,500 / $11,000) - English (PDF)
• SmartCare HMO-HSH-50/50% ($5,500 / $11,000) - English (PDF)
• SmartCare HMO-HS3-10/30% ($6,500 / $13,000) - English (PDF)
• SmartCare HMO-HS6-15/1500d ($6,500 / $13,000) - English (PDF)
• SmartCare HMO-HSG-40/1500d ($6,500 / $13,000) - English (PDF)
• SmartCare HMO-HSI-50/1500d ($6,500 / $13,000) - English (PDF)
• SmartCare HMO-HSJ-60/1500a ($8,700 / $17,400) - English (PDF)

Salud HMO y Más / Salud San Diego

• Salud y Más HMO-HU8-HU9-10/250a ($1,500 / $3,000) - English (PDF)
• Salud y Más HMO-HUC-HUD-15/250a ($2,500 / $7,500) - English (PDF)
• Salud y Más HMO-HUG-HUH-20/20% ($2,500 / $7,500) - English (PDF)
• Salud y Más HMO-HUL-HUM-30/20% ($2,500 / $7,500) - English (PDF)
• Salud y Más HMO-HUN-HUO-30/30% ($3,500 / $10,500) - English (PDF)
• Salud y Más HMO-HUJ-HUK-20/500a ($3,500 / $10,500) - English (PDF)
• Salud y Más HMO-HUP-HUQ-30/250d ($4,500 / $9,000) - English (PDF)
• Salud y Más HMO-HUX-HUY-40/500d ($4,500 / $9,000) - English (PDF)
• Salud y Más HMO-HU4-HU5-0/1000d ($5,500 / $11,000) - English (PDF)
• Salud y Más HMO-HUT-HUU-35/30% ($5,500 / $11,000) - English (PDF)
• Salud y Más HMO-HUV-HUW-40/40% ($5,500 / $11,000) - English (PDF)
• Salud y Más HMO-HU6-HU7-10/30% ($6,500 / $13,000) - English (PDF)
• Salud y Más HMO-HUE-HUF-15/1500d ($6,500 / $13,000) - English (PDF)
• Salud y Más HMO-HUZ-HV0-40/1500d ($6,500 / $13,000) - English (PDF)
• Salud y Más HMO-HV2-HV3-50/1500d ($6,500 / $13,000) - English (PDF)
• Salud y Más HMO-HV4-HV5-60/1500a ($8,700 / $17,400) - English (PDF)

Salud HMO y Más – Facility Deductible

• Salud y Más FD-HUI-20/500/10% ($3,500 / $10,500) - English (PDF)
• Salud y Más FD-HUR-30/1000/20% ($3,500 / $10,500) - English (PDF)
• Salud y Más FD-HUS-30/1500/30% ($3,500 / $10,500) - English (PDF)
• Salud y Más FD-HU3-0/1000/20% ($4,500 / $9,000) - English (PDF)
• Salud y Más FD-HUB-10/1500/30% ($5,500 / $11,000) - English (PDF)
• Salud y Más FD-HV1-40/3000/40% ($5,500 / $11,000) - English (PDF)
• Salud y Más FD-HV6-60/4000/40% ($8,700 / $17,400) - English (PDF)

Salud Mexico

• Salud Mexico-HU2-5/0 ($1,500 / $4,500) - English (PDF)

CanopyCare HMO

• CanopyCare HMO-HZ0-0/250a ($1,500 / $3,000) - English (PDF)
• CanopyCare HMO-HZ5-15/250a ($2,500 / $7,500) - English (PDF)
• CanopyCare HMO-HZ7-20/20% ($2,500 / $7,500) - English (PDF)
• CanopyCare HMO-HZC-20/1000a ($2,500 / $7,500) - English (PDF)
• CanopyCare HMO-HZF-30/20% ($2,500 / $7,500) - English (PDF)
• CanopyCare HMO-HZH-30/1500a ($2,500 / $7,500) - English (PDF)
• CanopyCare HMO-HZ9-20/500a ($3,500 / $10,500) - English (PDF)
• CanopyCare HMO-HZG-30/30% ($3,500 / $10,500) - English (PDF)
• CanopyCare HMO-HZ2-0/1000d ($5,500 / $11,000) - English (PDF)
• CanopyCare HMO-HZI-35/30% ($5,500 / $11,000) - English (PDF)
• CanopyCare HMO-HZJ-40/40% ($5,500 / $11,000) - English (PDF)
• CanopyCare HMO-HZK-40/1000d ($5,500 / $11,000) - English (PDF)
• CanopyCare HMO-HZ3-10/30% ($6,500 / $13,000) - English (PDF)
• CanopyCare HMO-HZ6-15/1500d ($6,500 / $13,000) - English (PDF)
• CanopyCare HMO-HZL-40/1500d ($6,500 / $13,000) - English (PDF)
• CanopyCare HMO-HZN-50/1500d ($6,500 / $13,000) - English (PDF)

CanopyCare HMO - Facility Deductible

• CanopyCare HMO FD-HZ8-20/500/10% ($3,000 / $6,000) - English (PDF)
• CanopyCare HMO FD-HZB-20/1000/20% ($3,000 / $6,000) - English (PDF)
• CanopyCare HMO FD-HZD-20/1500/20% ($4,000 / $8,000) - English (PDF)
• CanopyCare HMO FD-HZ1-0/1000/20% ($4,500 / $9,000) - English (PDF)
• CanopyCare HMO FD-HZE-20/2500/20% ($5,000 / $10,000) - English (PDF)
• CanopyCare HMO FD-HZ4-10/1500/30% ($5,500 / $11,000) - English (PDF)
• CanopyCare HMO FD-HZM-40/3000/30% ($6,000 / $12,000) - English (PDF)

POS-Elect Open Access (EOA)

• EOA-HTB-10/250a ($1,500 / $3,000) - English (PDF)
• EOA-HT8-10/0 ($2,500 / $7,500) - English (PDF)
• EOA-HTD-15/250a ($2,500 / $7,500) - English (PDF)
• EOA-HTF-20/20% ($2,500 / $7,500) - English (PDF)
• EOA-HTG-20/250a ($2,500 / $7,500) - English (PDF)
• EOA-HTK-30/20% ($2,500 / $7,500) - English (PDF)
• EOA-HTR-40/20% ($2,500 / $7,500) - English (PDF)
• EOA-HTI-20/500a ($3,500 / $10,500) - English (PDF)
• EOA-HTJ-20/500d ($3,500 / $10,500) - English (PDF)
• EOA-HTL-30/30% ($3,500 / $10,500) - English (PDF)
• EOA-HTS-40/30% ($3,500 / $10,500) - English (PDF)
• EOA-HTO-30/1000a ($3,500 / $10,500) - English (PDF)
• EOA-HTM-30/250d ($4,500 / $9,000) - English (PDF)
• EOA-HTU-40/500d ($4,500 / $9,000) - English (PDF)
• EOA-HT7-0/1000d ($5,500 / $11,000) - English (PDF)
• EOA-HTQ-35/30% ($5,500 / $11,000) - English (PDF)
• EOA-HTT-40/40% ($5,500 / $11,000) - English (PDF)
• EOA-HT9-10/30% ($6,500 / $13,000) - English (PDF)
• EOA-HTE-15/1500d ($6,500 / $13,000) - English (PDF)
• EOA-HTV-40/1500d ($6,500 / $13,000) - English (PDF)
• EOA-HTX-50/1500d ($6,500 / $13,000) - English (PDF)
• EOA-HTY-60/1500a ($8,700 / $17,400) - English (PDF)

POS-Elect Open Access (EOA) – Facility Deductible

• EOA FD-HTH-20/500/10% ($3,500 / $10,500) - English (PDF)
• EOA FD-HTN-30/1000/20% ($3,500 / $10,500) - English (PDF)
• EOA FD-HTP-30/1500/30% ($3,500 / $10,500) - English (PDF)
• EOA FD-HT6-0/1000/20% ($4,500 / $9,000) - English (PDF)
• EOA FD-HTC-10/1500/30% ($5,500 / $11,000) - English (PDF)
• EOA FD-HTW-40/3000/40% ($5,500 / $11,000) - English (PDF)
• EOA FD-HTZ-60/4000/40% ($8,700 / $17,400) - English (PDF)

ExcelCare EOA

• ExcelCare EOA-HVY-10/250a ($1,500 / $3,000) - English (PDF)
• ExcelCare EOA-HW0-15/250a ($2,500 / $7,500) - English (PDF)
• ExcelCare EOA-HW2-20/20% ($2,500 / $7,500) - English (PDF)
• ExcelCare EOA-HW3-20/250a ($2,500 / $7,500) - English (PDF)
• ExcelCare EOA-HW6-30/20% ($2,500 / $7,500) - English (PDF)
• ExcelCare EOA-HWE-40/20% ($2,500 / $7,500) - English (PDF)
• ExcelCare EOA-HW5-20/500a ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA-HW7-30/30% ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA-HWB-30/1000a ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA-HWF-40/30% ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA-HW8-30/250d ($4,500 / $9,000) - English (PDF)
• ExcelCare EOA-HWH-40/500d ($4,500 / $9,000) - English (PDF)
• ExcelCare EOA-HVW-0/1000d ($5,500 / $11,000) - English (PDF)
• ExcelCare EOA-HWD-35/30% ($5,500 / $11,000) - English (PDF)
• ExcelCare EOA-HWG-40/40% ($5,500 / $11,000) - English (PDF)
• ExcelCare EOA-HVZ-10/1500/30% ($5,500 / $11,000) - English (PDF)
• ExcelCare EOA-HVX-10/30% ($6,500 / $13,000) - English (PDF)
• ExcelCare EOA-HW1-15/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare EOA-HWI-40/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare EOA-HWK-50/1500d ($6,500 / $13,000) - English (PDF)
• ExcelCare EOA-HWL-60/1500a ($8,700 / $17,400) - English (PDF)

ExcelCare EOA - Facility Deductible

• ExcelCare EOA FD-HW4-20/500/10% ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA FD-HW9-30/1000/20% ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA FD-HWC-30/1500/30% ($3,500 / $10,500) - English (PDF)
• ExcelCare EOA FD-HVV-0/1000/20% ($4,500 / $9,000) - English (PDF)
• ExcelCare EOA FD-HWJ-40/3000/40% ($5,500 / $11,000) - English (PDF)
• ExcelCare EOA FD-HWM-60/4000/40% ($8,700 / $17,400) - English (PDF)

PPO

• PPO-HWO-0/1000/20% ($5,000 / $10,000) - English (PDF)
• PPO-HWP-10/0/10% ($2,000 / $6,000) - English (PDF)
• PPO-HWQ-10/0/10% ($3,000 / $9,000) - English (PDF)
• PPO-HWR-10/250/10% ($3,000 / $9,000) - English (PDF)
• PPO-HWU-15/250/10% ($3,000 / $9,000) - English (PDF)
• PPO-HWV-15/500/10% ($3,000 / $9,000) - English (PDF)
• PPO-HWY-20/250/10% ($3,000 / $9,000) - English (PDF)
• PPO-HX1-30/500/10% ($3,000 / $9,000) - English (PDF)
• PPO-HX4-30/1000/20% ($3,000 / $9,000) - English (PDF)
• PPO-HWS-10/250/20% ($4,000 / $12,000) - English (PDF)
• PPO-HWW-15/500/20% ($4,000 / $12,000) - English (PDF)
• PPO-HWZ-20/250/20% ($4,000 / $12,000) - English (PDF)
• PPO-HX0-20/500/20% ($4,000 / $12,000) - English (PDF)
• PPO-HX2-30/500/20% ($4,000 / $12,000) - English (PDF)
• PPO-HX3-30/500/30% ($4,000 / $12,000) - English (PDF)
• PPO-HX5-30/1000/20% ($4,000 / $12,000) - English (PDF)
• PPO-HX6-30/2000/30% ($5,000 / $10,000) - English (PDF)
• PPO-HX7-30/3000/30% ($5,000 / $10,000) - English (PDF)
• PPO-HWT-10/1500/30% ($6,000 / $12,000) - English (PDF)
• PPO-HX9-30/4000/30% ($6,000 / $12,000) - English (PDF)
• PPO-HX8-30/3000/30% ($6,000 / $12,000) - English (PDF)
• PPO-HWX-15/3000/30% ($7,000 / $14,000) - English (PDF)
• PPO-HXD-40/5000/30% ($7,000 / $14,000) - English (PDF)
• PPO-HXB-30/4000/30% ($7,000 / $14,000) - English (PDF)
• PPO-HXC-40/3500/30% ($7,000 / $14,000) - English (PDF)
• PPO-HXE-60/5000/30% ($8,700 / $17,400) - English (PDF)
• PPO-HXN-2800/0% F ($2,800 / $5,600) - English (PDF)

PPO (HSA-compatible) (Includes pre-set pharmacy plans)

• HSA-HXO-2800/30% F ($3,000 / $6,000) - English (PDF)
• HSA-HXP-2000/0% I ($2,000) - English (PDF)
• HSA-HXQ-1500/30% I ($3,000) - English (PDF)
• HSA-HXF-2800/0% ($2,800 / $5,600) - English (PDF)
• HSA-HXK-2800/30% ($3,000 / $6,000) - English (PDF)
• HSA-HXG-3000/0% ($3,000 / $6,000) - English (PDF)
• HSA-HXI-3000/20% ($4,000 / $8,000) - English (PDF)
• HSA-HXH-4000/0% ($4,000 / $8,000) - English (PDF)
• HSA-HXL-2800/30% ($5,000 / $10,000) - English (PDF)
• HSA-HXM-3000/30% ($5,000 / $10,000) - English (PDF)
• HSA-HXJ-5000/20% ($6,000 / $12,000) - English (PDF)

Pharmacy HMO

(combined medical and pharmacy OOPM)

• No deductible ($5/$25/$45) - D7A, D7B, D7C, D7D, D7E, D7F, D7G – English (PDF)
• No deductible ($10/$30/$50) - D7H, D7J, D7K, D7L, D7M, D7N, D7P – English (PDF)
• No deductible ($15/$35/$55) - D7Q, D7R, D7S, D7T, D7U, D7V, D7W – English (PDF)
• $100 deductible ($10/$30/$50) - D8E, D8F, D8G, D8H, D8J, D8K, D8L – English (PDF)
• $100 deductible ($15/$35/$55) - D7X, D7Y, D7Z, D8A, D8B, D8C, D8D – English (PDF)
• $300 deductible ($15/$40/$60) - D8M, D8N, D8P, D8Q, D8R, D8S, D8T – English (PDF)

Pharmacy POS – Elect Open Access (EOA)/ExcelCare EOA

• No deductible ($5/$25/$45) - D8U, D8V, D8W, D8X, D8Y, D8Z, D9A – English (PDF)
• No deductible ($10/$30/$50) - D9B, D9C, D9D, D9E, D9F, D9G, D9H – English (PDF)
• No deductible ($15/$35/$55) - D9J, D9K, D9L, D9M, D9N, D9P, D9Q – English (PDF)
• $100 deductible ($10/$30/$50) - D9R, D9S, D9T, D9U, D9V, D9W, D9X – English (PDF)
• $100 deductible ($15/$35/$55) - BA1, BA2, BA3, BA4, BA5, D9Y, D9Z – English (PDF)
• $300 deductible ($15/$40/$60) - BA6, BA7, BA8, BA9, BAA, BAB, BAC – English (PDF)

Pharmacy HMO – Salud HMO y Más

(combined medical and pharmacy OOPM)

• No deductible ($5/$25/$45) - D5W, D5X, D5Y, D5Z, D6A, D6B, D6C – English (PDF)
• No deductible ($10/$30/$50) - D6D, D6E, D6F, D6G, D6H, D6J, D6K – English (PDF)
• $100 deductible ($15/$35/$55) - D6L, D6M, D6N, D6P, D6Q, D6R, D6S – English (PDF)
• $300 deductible ($15/$40/$60) - D6T, D6U, D6V, D6W, D6X, D6Y, D6Z – English (PDF)

CanopyCare HMO

• No deductible ($5/$25/$45) - BC0, BC1, BC2, BC3, D7A, D7B, D7C, D7D, D7E, D7F – English (PDF)
• No deductible ($10/$30/$50) - BC4, BC5, BC6, BC7, D7H, D7J, D7K, D7L, D7M, D7N – English (PDF)
• No deductible ($15/$35/$55) - BC8, BC9, BCA, BCB, D7Q, D7R, D7S, D7T, D7U, D7V – English (PDF)
• $100 deductible ($10/$30/$50) - BCG, BCH, BCJ, BCK, D8E, D8F, D8G, D8H, D8J, D8K – English (PDF)
• $100 deductible ($15/$35/$55) - BCC, BCD, BCE, BCF, D7X, D7Y, D7Z, D8A, D8B, D8C – English (PDF)
• $300 deductible ($15/$40/$60) - BCL, BCM, BCN, BCP, D8M, D8N, D8P, D8Q, D8R, D8S – English (PDF)

Pharmacy PPO

(combined medical and pharmacy OOPM)

• No deductible ($5/$25/$45) - BAD, BAE, BAF, BAG, BAH, BAJ, BAK – English (PDF)
• No deductible ($10/$30/$50) - BAL, BAM, BAN, BAP, BAQ, BAR, BAS – English (PDF)
• No deductible ($15/$35/$55) - BAT, BAU, BAV, BAW, BAX, BAY, BAZ – English (PDF)
• $100 deductible ($10/$30/$50) - BB0, BB1, BB2, BB3, BB4, BB5, BB6 – English (PDF)
• $100 deductible ($15/$35/$55) - BB7, BB8, BB9, BBA, BBB, BBC, BBD – English (PDF)
• $300 deductible ($15/$40/$60) - BBE, BBF, BBG, BBH, BBJ, BBK, BBL – English (PDF)

Pharmacy HSA-compatible PPO

(combined medical and pharmacy OOPM)

• $1,500 deductible ($15/$35/$55) - D5K – English (PDF)
• $2,000 deductible ($0/$0/$0) - D5L – English (PDF)
• $2,800 deductible ($0/$0/$0) - D5Q, D5P – English (PDF)
• $2,800 deductible ($15/$35/$55) - D5O, D5N, D5M – English (PDF)
• $3,000 deductible ($0/$0/$0) - D5R – English (PDF)
• $3,000 deductible ($10/$30/$50) - D5S – English (PDF)
• $3,000 deductible ($15/$35/$55) - D5T – English (PDF)
• $4,000 deductible ($0/$0/$0) - D5U – English (PDF)
• $5,000 deductible ($10/$30/$50) - D5V – English (PDF)

Chiropractic / Acupuncture

• Chiropractic / Acupuncture – Combined – HMO/EOA – English (PDF)
• Chiropractic / Acupuncture – Combined – SmartCare $15 – English (PDF)
• Chiropractic / Acupuncture – Combined – SmartCare $25 – English (PDF)
• Chiropractic / Acupuncture – Combined – Custom – English (PDF)

Chiropractic Care

Chiropractic Care – HMO/EOA – English (PDF)

Dental – HMO

• Dental – HMO – Health Net Plus 85 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 85 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 100 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 100 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 150 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 185 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 185 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 225 – Schedule of Benefits – English (PDF)

Dental – PPO

• Dental – PPO – Classic 1 1500 – English (PDF)
• Dental – PPO – Classic 2 1500 – English (PDF)
• Dental – PPO – Classic 3 1500 – English (PDF)
• Dental – PPO – Classic 4 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Classic 6 1500 – English (PDF)
• Dental – PPO – Classic Plus 1 2000 – English (PDF)
• Dental – PPO – Classic Plus 2 2000 – English (PDF)
• Dental – PPO – Essential 1 1000 – English (PDF)
• Dental – PPO – Essential 2 1000 – English (PDF)
• Dental – PPO – Essential 2 1000 – En Español (Spanish) (PDF)
• Dental – PPO – Essential 3 1000 – English (PDF)
• Dental – PPO – Essential 4 1000 – English (PDF)
• Dental – PPO – Essential 5 1500 – English (PDF)
• Dental – PPO – Essential 6 1500 – English (PDF)
• Dental – PPO – Essential 6 1500 – En Español (Spanish) (PDF)
• Dental – PPO – Essential Value 1 1000 – English (PDF)
• Dental – PPO – Basic 500 – English (PDF)

Vision Plans

• Vision Plans – Exam Only – English (PDF)
• Vision Plans – Elite 1010-1 – English (PDF)
• Vision Plans – Plus 20-1 – English (PDF)
• Vision Plans – Preferred 1025-2 – English (PDF)
• Vision Plans – Preferred 1025-3 – English (PDF)
• Vision Plans – Preferred 1025-3 – En Español (Spanish) (PDF)
• Vision Plans – Preferred Value 10-3 – English (PDF)
• Vision Plans – Supreme 010-2 – English (PDF)

Full Network HMO

• Full Network HMO-GWY-15/0 ($2,500 / $7,500) (PDF)
• Full Network HMO-GWX-10/250a ($1,500 / $3,000) (PDF)
• Full Network HMO-GWZ-15/250a ($2,500 / $7,500)(PDF)
• Full Network HMO-GX2-20/250a ($2,500 / $7,500) (PDF)
• Full Network HMO-GX3-20/500a ($3,000 / $9,000) (PDF)
• Full Network HMO-GX4-20/500d ($3,000 / $9,000) (PDF)
• Full Network HMO-GX1-20/20% ($2,500 / $7,500) (PDF)
• Full Network HMO-GX8-30/1000a ($3,000 / $9,000) (PDF)
• Full Network HMO-GX5-30/20% ($2,500 / $7,500) (PDF)
• Full Network HMO-GX6-30/30% ($3,000 / $9,000) (PDF)
• Full Network HMO-GX9-35/30% ($5,500 / $11,000) (PDF)
• Full Network HMO-GXB-40/20% ($2,500 / $7,500) (PDF)
• Full Network HMO-GXC-40/30% ($3,000 / $9,000) (PDF)
• Full Network HMO-GXD-40/40% ($5,500 / $11,000) (PDF)
• Full Network HMO-GX7-30/250d ($4,500 / $9,000) (PDF)
• Full Network HMO-GXE-40/500d ($4,500 / $9,000) (PDF)
• Full Network HMO-GX0-15/1500d ($5,850 / $11,700) (PDF)
• Full Network HMO-GXF-40/1500d ($6,500 / $13,000) (PDF)
• Full Network HMO-GXG-50/1500d ($5,850 / $11,700) (PDF)
• Full Network HMO-GXH-60/1500a ($5,850 / $11,700) (PDF)
• Full Network HMO-GXI-60/1500a ($8,550 / $17,100) (PDF)

ExcelCare HMO

• ExcelCare HMO-GXJ-10/250a ($1,500 / $3,000) (PDF)
• ExcelCare HMO-GXK-15/250a ($2,500 / $7,500) (PDF)
• ExcelCare HMO-GXN-20/250a ($2,500 / $7,500) (PDF)
• ExcelCare HMO-GXO-20/500a ($3,000 / $9,000) (PDF)
• ExcelCare HMO-GXM-20/20% ($2,500 / $7,500) (PDF)
• ExcelCare HMO-GXS-30/1000a ($3,000 / $9,000) (PDF)
• ExcelCare HMO-GXP-30/20% ($2,500 / $7,500) (PDF)
• ExcelCare HMO-GXQ-30/30% ($3,000 / $9,000) (PDF)
• ExcelCare HMO-GXT-35/30% ($5,500 / $11,000) (PDF)
• ExcelCare HMO-GXU-40/30% ($3,000 / $9,000) (PDF)
• ExcelCare HMO-GXV-40/40% ($5,500 / $11,000) (PDF)
• ExcelCare HMO-GXR-30/250d ($4,500 / $9,000) (PDF)
• ExcelCare HMO-GXW-40/500d ($4,500 / $9,000) (PDF)
• ExcelCare HMO-GXL-15/1500d ($5,850 / $11,700) (PDF)
• ExcelCare HMO-GXX-40/1500d ($6,500 / $13,000) (PDF)
• ExcelCare HMO-GXY-50/1500d ($5,850 / $11,700) (PDF)
• ExcelCare HMO-GXZ-60/1500a ($5,850 / $11,700) (PDF)
• ExcelCare HMO-GY0-60/1500a ($8,550 / $17,100) (PDF)

SmartCare HMO

• SmartCare HMO-GWH-10/250a ($1,500 / $3,000) (PDF)
• SmartCare HMO-GWI-15/250a ($2,500 / $7,500) (PDF)
• SmartCare HMO-GWL-20/500a ($3,000 / $9,000) (PDF)
• SmartCare HMO-GWO-30/250d ($4,500 / $9,000) (PDF)
• SmartCare HMO-GWR-40/500d ($4,500 / $9,000) (PDF)
• SmartCare HMO-GWK-20/20% ($2,500 / $7,500) (PDF)
• SmartCare HMO-GWM-30/20% ($2,500 / $7,500) (PDF)
• SmartCare HMO-GWN-30/30% ($3,000 / $9,000) (PDF)
• SmartCare HMO-GWP-35/30% ($5,500 / $11,000) (PDF)
• SmartCare HMO-GWQ-40/40% ($5,500 / $11,000) (PDF)
• SmartCare HMO-GWT-50/50% ($5,500 / $11,000) (PDF)
• SmartCare HMO-GWJ-15/1500d ($5,850 / $11,700) (PDF)
• SmartCare HMO-GWS-40/1500d ($6,500 / $13,000) (PDF)
• SmartCare HMO-GWU-50/1500d ($5,850 / $11,700) (PDF)
• SmartCare HMO-GWV-60/1500a ($5,850 / $11,700) (PDF)
• SmartCare HMO-GWW-60/1500a ($8,550 / $17,100) (PDF)

Salud HMO y Más / Salud San Diego

• Salud-H0Y/H0M-10/250a ($1,500 / $3,000) (PDF)
• Salud-H0N/H0P-15/250a ($2,500 / $7,500) (PDF)
• Salud-H13/H14-20/500a ($3,000 / $9,000) (PDF)
• Salud-H19/H1B-30/250d ($4,500 / $9,000) (PDF)
• Salud-H1G/H1H-40/500d ($4,500 / $9,000) (PDF)
• Salud-H11/H12-20/20% ($2,500 / $7,500) (PDF)
• Salud-H15/H16-30/20% ($2,500 / $7,500) (PDF)
• Salud-H17/H18-30/30% ($3,000 / $9,000)(PDF)
• Salud-H1C/H1D-35/30% ($5,500 / $11,000) (PDF)
• Salud-H1E/H1F-40/40% ($5,500 / $11,000) (PDF)
• Salud-H0Z/H10-15/1500d ($5,850 / $11,700) (PDF)
• Salud-H1L/H1M-50/1500d ($5,850 / $11,700) (PDF)
• Salud-H1J/H1K-40/1500d ($6,500 / $13,000) (PDF)
• Salud-H0U/H0V-60/1500a ($5,850 / $11,700) (PDF)
• Salud-H1N/H0W-60/1500a ($8,550 / $17,100) (PDF)

Salud HMO y Más – Facility Deductible

• Salud-FD-H0Q-20/500/10% ($3,000 / $9,000) (PDF)
• Salud-FD-H0R-30/1000/20% ($3,000 / $9,000) (PDF)
• Salud-FD-H0S-30/1500/30% ($3,000 / $9,000) (PDF)
• Salud-FD-H0T-40/3000/40% ($5,500 / $11,000) (PDF)
• Salud-FD-H0X-60/4000/40% ($8,550 / $17,100) (PDF)

Salud Mexico

• Salud-FD-H0J-5/0 ($1,500 / $4,500) (PDF)

New for 2021! – CanopyCare HMO

• CanopyCare-H6Q-0/250a ($1,500 / $3,000) (PDF)
• CanopyCare-H6R-15/250a ($2,500 / $7,500) (PDF)
• CanopyCare-H6U-20/500a ($3,000 / $9,000) (PDF)
• CanopyCare-H6V-20/1000a ($2,500 / $7,500) (PDF)
• CanopyCare-H6Y-30/1500a ($2,500 / $7,500) (PDF)
• CanopyCare-H6T-20/20% ($2,500 / $7,500) (PDF)
• CanopyCare-H6W-30/20% ($2,500 / $7,500) (PDF)
• CanopyCare-H6X-30/30% ($3,000 / $9,000) (PDF)
• CanopyCare-H6Z-35/30% ($5,500 / $11,000) (PDF)
• CanopyCare-H70-40/40% ($5,500 / $11,000) (PDF)
• CanopyCare-H6S-15/1500d ($5,850 / $11,700) (PDF)
• CanopyCare-H71-40/1000d ($5,500 / $11,000) (PDF)
• CanopyCare-H72-40/1500d ($6,500 / $13,000) (PDF)
• CanopyCare-H73-50/1500d ($5,850 / $11,700) (PDF)
• CanopyCare-H74-60/1500a ($8,550 / $17,100) (PDF)

POS-Elect Open Access (EOA)

• EOA-GZ1-10/0 ($2,500 / $7,500) (PDF)
• EOA-GZ2-10/250a ($1,500 / $3,000) (PDF)
• EOA-GZ3-15/250a ($2,500 / $7,500) (PDF)
• EOA-GZE-20/250a ($2,500 / $7,500) (PDF)
• EOA-GZK-30/250d ($4,500 / $9,000) (PDF)
• EOA-GZG-20/500d ($3,000 / $9,000) (PDF)
• EOA-GZF-20/500a ($3,000 / $9,000) (PDF)
• EOA-GZL-30/1000a ($3,000 / $9,000) (PDF)
• EOA-GZ7-40/500d ($4,500 / $9,000) (PDF)
• EOA-GZD-20/20% ($2,500 / $7,500) (PDF)
• EOA-GZH-30/20% ($2,500 / $7,500) (PDF)
• EOA-GZM-40/20% ($2,500 / $7,500) (PDF)
• EOA-GZJ-30/30% ($3,000 / $9,000) (PDF)
• EOA-GZI-35/30% ($5,500 / $11,000) (PDF)
• EOA-GZ5-40/30% ($3,000 / $9,000) (PDF)
• EOA-GZ6-40/40% ($5,500 / $11,000) (PDF)
• EOA-GZ4-15/1500d ($5,850 / $11,700) (PDF)
• EOA-GZ9-40/1500d ($6,500 / $13,000) (PDF)
• EOA-GZ8-50/1500d ($5,850 / $11,700) (PDF)
• EOA-GZB-60/1500a ($5,850 / $11,700) (PDF)
• EOA-GZC-60/1500a ($8,550 / $17,100) (PDF)

POS-Elect Open Access (EOA) – Facility Deductible

• EOA-FD-GZQ-20/500/10% ($3,000 / $9,000) (PDF)
• EOA-FD-GZR-30/1000/20% ($3,000 / $9,000) (PDF)
• EOA-FD-GZN-30/1500/30% ($3,000 / $9,000) (PDF)
• EOA-FD-GZO-40/3000/40% ($5,500 / $11,000) (PDF)
• EOA-FD-GZP-60/4000/40% ($8,550 / $17,100) (PDF)

ExcelCare EOA

• ExcelCare EOA-GZS-10/250a ($1,500 / $3,000) (PDF)
• ExcelCare EOA-GZT-15/250a ($2,500 / $7,500) (PDF)
• ExcelCare EOA-GZW-20/250a ($2,500 / $7,500) (PDF)
• ExcelCare EOA-GZX-20/500a ($3,000 / $9,000) (PDF)
• ExcelCare EOA-GZZ-30/250d ($4,500 / $9,000) (PDF)
• ExcelCare EOA-H00-30/1000a ($3,000 / $9,000)(PDF)
• ExcelCare EOA-H04-40/500d ($4,500 / $9,000) (PDF)
• ExcelCare EOA-GZV-20/20% ($2,500 / $7,500) (PDF)
• ExcelCare EOA-GZY-30/20% ($2,500 / $7,500) (PDF)
• ExcelCare EOA-H0B-30/30% ($3,000 / $9,000) (PDF)
• ExcelCare EOA-H09-35/30% ($5,500 / $11,000) (PDF)
• ExcelCare EOA-H01-40/20% ($2,500 / $7,500) (PDF)
• ExcelCare EOA-H02-40/30% ($3,000 / $9,000) (PDF)
• ExcelCare EOA-H03-40/40% ($5,500 / $11,000) (PDF)
• ExcelCare EOA-GZU-15/1500d ($5,850 / $11,700) (PDF)
• ExcelCare EOA-H06-40/1500d ($6,500 / $13,000) (PDF)
• ExcelCare EOA-H05-50/1500d ($5,850 / $11,700) (PDF)
• ExcelCare EOA-H07-60/1500a ($5,850 / $11,700) (PDF)
• ExcelCare EOA-H08-60/1500a ($8,550 / $17,100) (PDF)

ExcelCare EOA - Facility Deductible

• EC-EOA-FC-H0F-20/500/10% ($3,000 / $9,000) (PDF)
• EC-EOA-FC-H0G-30/1000/20% ($3,000 / $9,000)(PDF)
• EC-EOA-FC-H0C-30/1500/30% ($3,000 / $9,000) (PDF)
• EC-EOA-FC-H0D-40/3000/40% ($5,500 / $11,000) (PDF)
• EC-EOA-FC-H0E-60/4000/40% ($8,550 / $17,100) (PDF)

PPO

• PPO-GY1-10/0/10% ($2,000 / $6,000) (PDF)
• PPO-GY2-10/0/10% ($3,000 / $9,000) (PDF)
• PPO-GY3-10/250/10% ($3,000 / $9,000)(PDF)
• PPO-GY4-10/250/20% ($4,000 / $12,000) (PDF)
• PPO-GY5-15/250/10% ($3,000 / $9,000) (PDF)
• PPO-GY6-15/500/10% ($3,000 / $9,000) (PDF)
• PPO-GY7-15/500/20% ($4,000 / $12,000) (PDF)
• PPO-GY8-20/250/10% ($3,000 / $9,000) (PDF)
• PPO-GY9-20/250/20% ($4,000 / $12,000)(PDF)
• PPO-GYB-20/500/20% ($4,000 / $12,000)(PDF)
• PPO-GYC-30/500/10% ($3,000 / $9,000) (PDF)
• PPO-GYD-30/500/20% ($4,000 / $12,000) (PDF)
• PPO-GYE-30/500/30% ($4,000 / $12,000) (PDF)
• PPO-GYF-30/1000/20% ($3,000 / $9,000) (PDF)
• PPO-GYG-30/1000/20% ($4,000 / $12,000) (PDF)
• PPO-GYH-30/2000/30% ($5,000 / $10,000) (PDF)
• PPO-GYI-30/3000/30% ($5,000 / $10,000) (PDF)
• PPO-GYJ-30/3000/30% ($6,000 / $12,000) (PDF)
• PPO-GYM-30/4000/30% ($5,600 / $11,200) (PDF)
• PPO-GYL-40/3500/30% ($7,350 / $14,700) (PDF)
• PPO-GYK-30/4000/30% ($6,600 / $13,200) (PDF)
• PPO-GYN-60/5000/30% ($6,350 / $12,700) (PDF)
• PPO-GYO-60/5000/30% ($8,550 / $17,100) (PDF)

PPO (HSA-compatible) (Includes pre-set pharmacy plans)

• HSA-GYY-2800/30% F ($3,000 / $6,000) (PDF)
• HSA-GZ0-1500/30% I ($3,000) (PDF)
• HSA-GYV-2800/30% ($5,000 / $10,000) (PDF)
• HSA-GYP-2800/0% ($2,800 / $5,600) (PDF)
• HSA-GYU-2800/30% ($3,000 / $6,000) (PDF)
• HSA-GYW-3000/30% ($5,000 / $10,000) (PDF)
• HSA-GYX-2800/0% F ($2,800 / $5,600) (PDF)
• HSA-GYZ-2000/0% I ($2,000) (PDF)
• HSA-GYQ-3000/0% ($3,000 / $6,000) (PDF)
• HSA-GYS-3000/20% ($4,000 / $8,000) (PDF)
• HSA-GYT-5000/20% ($6,000 / $12,000) (PDF)
• HSA-GYR-4000/0% ($4,000 / $8,000) (PDF)

Pharmacy HMO

(combined medical and pharmacy OOPM)

• No deductible ($10/$30/$50)-74W,74X,74Z,75A,75B,75C,81U,81V (PDF)
• No deductible ($15/$35/$55)-75M,75N,75P,75Q,75R,75S,81W,81X (PDF)
• $100 deductible ($10/$30/$50)-75E,75F,75G,75I,75J,75K,82A,82B (PDF)
• $100 deductible ($15/$35/$55)-75U,75V,75X,75Y,75Z,76A,81Y,81Z (PDF)
• $300 deductible ($15/$40/$60)-76C,76D,76F,76G,76H,76I,82C,82D (PDF)

Pharmacy POS – Elect Open Access (EOA)/ExcelCare EOA

(combined medical and pharmacy OOPM)

• No deductible ($10/$30/$50)-74B,74C,74D,74E,74F,74G,81C,81D (PDF)
• No deductible ($15/$35/$55)-73G,73H,73I,73J,73K,73L,81E,81F (PDF)
• $100 deductible ($10/$30/$50)-73N,73O,73P,73Q,73R,73S,81G,81H (PDF)
• $100 deductible ($15/$35/$55)-74P,74Q,74R,74S,74T,74U,81I,81J (PDF)
• $300 deductible ($15/$40/$60)-73U,73V,73W,73X,73Y,73Z,81K,81L (PDF)

Pharmacy HMO – Salud HMO y Más

(combined medical and pharmacy OOPM)

• No deductible ($5/$25/$45)-71X,71Y,71Z,72A,72B,72C,81M,81N (PDF)
• No deductible ($10/$30/$50)-72E,72F,72G,72H,72I,72J,81O,81P (PDF)
• $100 deductible ($15/$35/$55)-72L,72M,72N,72O,72P,72Q,81Q,81R (PDF)
• $300 deductible ($15/$40/$60)-72Z,73A,73B,73C,73D,73E,81S,81T (PDF)

New for 2021! – CanopyCare HMO

(combined medical and pharmacy OOPM)

• No deductible ($10/$30/$50)-74W,74X,74Z,75B,75C,81U,81V (PDF)
• No deductible ($15/$35/$55)-75M,75N,75P,75R,75S,81W,81X (PDF)
• $100 deductible ($10/$30/$50)-75E,75F,75G,75J,75K,82A,82B (PDF)
• $100 deductible ($15/$35/$55)-75U,75V,75X,75Z,76A,81Y,81Z (PDF)
• $300 deductible ($15/$40/$60)-76C,76D,76F,76H,76I,82C,82D (PDF)

Pharmacy PPO

(combined medical and pharmacy OOPM)

• No deductible ($10/$30/$50)-82E,82F,82G,82H,82I,82J,82K,82L,82M,82N (PDF)
• No deductible ($15/$35/$55)-82O,82P,82Q,82R,82S,82T,82U,82V,82W,82X (PDF)
• $100 deductible ($10/$30/$50)-82Y,82Z,83A,83B,83C,83D,83E,83F,83G,83H (PDF)
• $100 deductible ($15/$35/$55)-83I,83J,83K,83L,83M,83N,83O,83P,83Q,83R (PDF)
• $300 deductible ($15/$40/$60)-83S,83T,83U,83V,83W,83X,83Y,83Z,84A,84B (PDF)

Pharmacy PPO- HSA compatible

(combined medical and pharmacy OOPM)

• $1,500 deductible ($15/$35/$55)-84C (PDF)
• $2,000 deductible ($0/$0/$0)-84D (PDF)
• $2,800 deductible ($0/$0/$0)-84H,84I (PDF)
• $2,800 deductible ($15/$35/$55)-84E,84F,84G (PDF)
• $3,000 deductible ($0/$0/$0)-84J (PDF)
• $3,000 deductible ($10/$30/$50)-84K (PDF)
• $3,000 deductible ($15/$35/$55)-84L (PDF)
• $4,000 deductible ($0/$0/$0)-84M (PDF)
• $5,000 deductible ($10/$30/$50)-84N (PDF)

Chiropractic / Acupuncture

• Chiropractic / Acupuncture – Combined – HMO/EOA – English (PDF)
• Chiropractic / Acupuncture – Combined – SmartCare – English (PDF)
• Chiropractic / Acupuncture – Combined – Custom – English (PDF)

Chiropractic Care

Chiropractic Care – HMO/EOA – English (PDF)

Dental – HMO

• Dental – HMO – Health Net Plus 85 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 85 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 85 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 100 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 100 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 100 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 150 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 150 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 185 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 185 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 185 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – English (PDF)
• Dental – HMO – Health Net Plus 225 – Plan Overview – En Español (Spanish) (PDF)
• Dental – HMO – Health Net Plus 225 – Schedule of Benefits – English (PDF)
• Dental – HMO – Health Net Value 225 – English (PDF)
• Dental – HMO – Health Net Value 225 – En Español (Spanish) (PDF)

Dental – PPO

• Dental – PPO – Classic 1 1500 – English (PDF)
• Dental – PPO – Classic 2 1500 – English (PDF)
• Dental – PPO – Classic 3 1500 – English (PDF)
• Dental – PPO – Classic 4 1500 – English (PDF)
• Dental – PPO – Classic 5 1500 – English (PDF)
• Dental – PPO – Classic 6 1500 – English (PDF)
• Dental – PPO – Classic Plus 1 2000 – English (PDF)
• Dental – PPO – Classic Plus 2 2000 – English (PDF)
• Dental – PPO – Essential 1 1000 – English (PDF)
• Dental – PPO – Essential 2 1000 – English (PDF)
• Dental – PPO – Essential 3 1000 – English (PDF)
• Dental – PPO – Essential 4 1000 – English (PDF)
• Dental – PPO – Essential 5 1500 – English (PDF)
• Dental – PPO – Essential 5 1500 – Spanish (PDF)
• Dental – PPO – Essential 6 1500 – English (PDF)
• Dental – PPO – Essential Value 1 1000 – English (PDF)
• Dental – PPO – Basic 500 – English (PDF)

Vision Plans

• Vision Plans – Exam Only – English (PDF)
• Vision Plans – Elite 1010-1 – English (PDF)
• Vision Plans – Plus 20-1 – English (PDF)
• Vision Plans – Preferred 1025-2 – English (PDF)
• Vision Plans – Preferred 1025-3 – English (PDF)
• Vision Plans – Preferred 1025-3 – Spanish (PDF)
• Vision Plans – Preferred Value 10-3 – English (PDF)
• Vision Plans – Supreme 010-2 – English (PDF)

Refer to County Reference Quick Guide to determine service areas in each directory.

• Tailored Networks Comparison Lists – Northern California – English (PDF)
  
• Tailored Networks Comparison Lists – Central California – English (PDF)
  
• Tailored Networks Comparison Lists – Los Angeles County – English (PDF)
  
• Tailored Networks Comparison Lists – Orange County – English (PDF)
  
• Tailored Networks Comparison Lists – Riverside County – English (PDF)
  
• Tailored Networks Comparison Lists – San Bernardino County – English (PDF)
  
• Tailored Networks Comparison Lists – San Diego County – English (PDF)
• How Soon Can I See the Doctor – English (PDF)
• How Soon Can I See the Doctor – En Español (Spanish) (PDF)
• ProviderSearch Information – English (PDF)
• ProviderSearch Information – En Español (Spanish) (PDF)
• County Reference Quick Guide – English (PDF)