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2018 Annual Notice of Change

HMO Members

Gold Select (HMO)

English 0kB   12/31/69

En Español (Spanish) 0kB   12/31/69

•Los Angeles, Orange


Gold Select (HMO)

English 0kB   12/31/69

En Español (Spanish) 0kB   12/31/69

•Riverside, San Bernardino


Green (HMO)

English 280kB   02/01/18

En Español (Spanish) 286kB   02/01/18

•Los Angeles, Riverside & San Bernardino


Green (HMO)

English 104kB   02/01/18

En Español (Spanish) 465kB   02/01/18

•Alameda, Placer, Sacramento, Sonoma & Stanislaus


Healthy Heart (HMO)

English 294kB   02/01/18

En Español (Spanish) 509kB   02/01/18

•Alameda & Stanislaus


Healthy Heart (HMO)

English 280kB   02/01/18

En Español (Spanish) 501kB   02/01/18

•Fresno


Healthy Heart (HMO)

English 292kB   02/01/18

En Español (Spanish) 504kB   02/01/18

•Los Angeles, Orange


Healthy Heart (HMO)

English 279kB   02/01/18

En Español (Spanish) 500kB   02/01/18

•Riverside & San Bernardino


Healthy Heart (HMO)

English 288kB   02/01/18

En Español (Spanish) 527kB   02/01/18

•San Diego


Healthy Heart (HMO)

English 292kB   02/01/18

Chinese (Chinese) 683kB   02/01/18

•San Francisco


Healthy Heart (HMO)

English 602kB   02/01/18

En Español (Spanish) 511kB   02/01/18

•Yolo


Healthy Heart (HMO)

English 296kB   02/01/18

•Placer, Sacramento


Ruby (HMO)

English 284kB   02/01/18

En Español (Spanish) 514kB   02/01/18

•Kern


Ruby (HMO)

English 604kB   02/01/18

En Español (Spanish) 511kB   02/01/18

•Santa Clara


Ruby Select (HMO)

English 283kB   02/01/18

Chinese (Chinese) 403kB   02/01/18

•San Francisco


Ruby Select (HMO)

English 283kB   02/01/18

En Español (Spanish) 304kB   02/01/18

•Fresno


Ruby Select (HMO)

English 297kB   02/01/18

En Español (Spanish) 515kB   02/01/18

•Alameda


Ruby Select (HMO)

English 296kB   02/01/18

En Español (Spanish) 512kB   02/01/18

•Yolo


Sapphire (HMO)

English 321kB   02/01/18

En Español (Spanish) 342kB   02/01/18

•Los Angeles, Orange & San Diego


Sapphire (HMO)

English 320kB   02/01/18

En Español (Spanish) 709kB   02/01/18

•Kern


Sapphire (HMO)

English 319kB   02/01/18

En Español (Spanish) 618kB   02/01/18

•Riverside & San Bernardino


Sapphire Primier (HMO)

English 318kB   02/01/18

En Español (Spanish) 709kB   02/01/18

•Fresno, Los Angeles, Orange, San Diego & San Francisco


Sapphire Primier (HMO)

English 327kB   02/01/18

En Español (Spanish) 799kB   02/01/18

•Riverside & San Bernardino


HMO SNP Members
HMO Special Needs Plan

Amber I (HMO SNP)

English 695kB   02/01/18

En Español (Spanish) 601kB   02/01/18

•Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare


Amber II (HMO SNP)

English 292kB   02/01/18

En Español (Spanish) 504kB   02/01/18

•Fresno, Los Angeles, Orange, San Diego & San Francisco


Amber II (HMO SNP)

English 311kB   02/01/18

En Español (Spanish) 320kB   02/01/18

•Kern, Tulare


Amber II (HMO SNP)

English 137kB   02/01/18

En Español (Spanish) 597kB   02/01/18

•Riverside, San Bernardino


Amber II Primier (HMO SNP)

English 700kB   02/01/18

En Español (Spanish) 609kB   02/01/18

•Fresno


Jade (HMO SNP)

English 293kB   02/01/18

En Español (Spanish) 504kB   02/01/18

•Kern, Los Angeles & Orange


2018 Evidence of Coverage

Amber I (HMO SNP)

Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Tulare

English 1.5MB   02/22/18

En Español (Spanish) 1.6MB   02/25/18


Amber II (HMO SNP)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Kern & Tulare

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Riverside & San Bernardino

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Amber II Premier (HMO SNP)

Fresno

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Gold Select (HMO)

Los Angeles, Orange

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Riverside, San Bernardino

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Green (HMO)

Los Angeles, Riverside & San Bernardino

English 1.2MB   02/22/18

En Español (Spanish) 1.2MB   02/25/18


Alameda, Placer, Sacramento, Sonoma & Stanislaus

English 1.3MB   02/22/18

En Español (Spanish) 1.4MB   02/25/18


Healthy Heart (HMO)

Alameda & Stanislaus

English 1.6MB   02/22/18

En Español (Spanish) 1.7MB   02/25/18


Fresno

English 1.6MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Los Angeles, Orange

English 1.6MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Riverside & San Bernardino

English 1.5MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


San Diego

English 1.5MB   02/22/18

En Español (Spanish) 1.7MB   02/25/18


San Francisco

English 1.5MB   02/22/18

Chinese (Chinese) 1.9MB   02/25/18


Yolo

English 1.5MB   02/22/18

En Español (Spanish) 1.7MB   02/25/18


Placer, Sacramento

English 1.5MB   02/25/18


Jade (HMO SNP)

Kern, Los Angeles & Orange

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


San Diego

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Ruby Select (HMO)

San Francisco

English 1.7MB   02/25/18

Chinese (Chinese) 1.9MB   02/25/18


Fresno

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Alameda

English 1.6MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Yolo

English 1.6MB   02/25/18

En Español (Spanish) 1.7MB   02/25/18


Ruby (HMO)

Kern

English 1.6MB   02/22/18

En Español (Spanish) 1.7MB   02/25/18


Santa Clara

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Sapphire (HMO)

Los Angeles, Orange & San Diego

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Kern

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Riverside & San Bernardino

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


Sapphire Premier (HMO)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 1.5MB   02/25/18

En Español (Spanish) 1.5MB   02/25/18


Riverside & San Bernardino

English 1.5MB   02/25/18

En Español (Spanish) 1.6MB   02/25/18


2018 Summary of Benefits

Amber I (HMO SNP)

Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Tulare

English 1.1MB   02/02/18

En Español (Spanish) 863kB   02/07/18


Amber II (HMO SNP)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 578kB   02/02/18

En Español (Spanish) 849kB   02/07/18


Kern & Tulare

English 696kB   02/02/18

En Español (Spanish) 947kB   02/07/18


Riverside & San Bernardino

English 790kB   02/02/18

En Español (Spanish) 620kB   02/07/18


Amber II Premier (HMO SNP)

Fresno

English 582kB   02/02/18

En Español (Spanish) 1.2MB   02/07/18


Gold Select (HMO)

Los Angeles, Orange

English 603kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Riverside, San Bernardino

English 602kB   02/02/18

En Español (Spanish) 978kB   02/07/18


Green (HMO)

Los Angeles, Riverside & San Bernardino

English 523kB   02/02/18

En Español (Spanish) 990kB   02/07/18


Alameda, Placer, Sacramento, Sonoma & Stanislaus

English 533kB   02/02/18

En Español (Spanish) 990kB   02/07/18


Healthy Heart (HMO)

Alameda & Stanislaus

English 563kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Fresno

English 542kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Los Angeles, Orange

English 541kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Riverside & San Bernardino

English 541kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


San Diego

English 535kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


San Francisco

English 535kB   02/02/18

Chinese (Chinese) 1.5MB   02/07/18


Yolo

English 534kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Placer, Sacramento

English 705kB   02/02/18


Jade (HMO SNP)

Kern, Los Angeles & Orange

English 530kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


San Diego

English 534kB   02/02/18


Ruby Select (HMO)

San Francisco

English 541kB   02/02/18

Chinese (Chinese) 1.1MB   02/07/18


Fresno

English 531kB   02/02/18

En Español (Spanish) 971kB   02/07/18


Alameda

English 644kB   02/02/18

En Español (Spanish) 791kB   02/07/18


Yolo

English 541kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Ruby (HMO)

Kern

English 543kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Santa Clara

English 537kB   02/02/18

En Español (Spanish) 1.1MB   02/07/18


Sapphire (HMO)

Los Angeles, Orange & San Diego

English 535kB   02/02/18

En Español (Spanish) 975kB   02/07/18


Kern

English 534kB   02/02/18

En Español (Spanish) 977kB   02/07/18


Riverside & San Bernardino

English 986kB   02/07/18

En Español (Spanish) 986kB   02/12/18


Sapphire Premier (HMO)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 536kB   02/02/18


Riverside & San Bernardino

English 533kB   02/02/18


2018 Forms


Enrollment Form

English 144kB   03/27/18

En Español (Spanish) 79kB   02/01/18

Chinese (Chinese) 4.3MB   02/12/18


Abbreviated Enrollment Form

English 0kB   12/31/69


Pre-enrollment Qualification

English 408kB   02/01/18

En Español (Spanish) 44kB   02/01/18

Special Needs Plan (SNP) designed for people with chronic conditions such as diabetes, chronic heart failure and certain cardiovascular disorders.


Chronic Condition Verification Form

English 408kB   02/01/18


Optional Supplemental Benefits Enrollment Form

English 427kB   02/01/18

En Español (Spanish) 79kB   02/01/18

Chinese (Chinese) 686kB   02/12/18


Transition of Care Form

English 384kB   02/12/18


Medicare Advantage Member Claim form

English 1MB   02/01/18


Disenrollment Form

English 611kB   02/01/18


2018 Flyers, Brochures & Inserts


Multi-Language Insert

Multilingual 369kB   02/01/18


National Coverage Determination Notice

English 674kB   01/29/18


Quick Reference Guide

English 156kB   02/01/18

En Español (Spanish) 260kB   02/01/18

Chinese (Chinese) 1.2MB   02/01/18


Directory Flyer

English 477kB   02/01/18

En Español (Spanish) 492kB   02/01/18

Chinese (Chinese) 1.5MB   02/01/18


Medicare Newsletter

English 5.4MB   02/01/18

En Español (Spanish) 6.6MB   02/01/18

Chinese (Chinese) 21.3MB   02/01/18


Pharmacy

Mail Order Pharmacy

CVS Caremark Mail Order Pharmacy

English 147kB   11/29/17

En Español (Spanish) 151kB   11/29/17


Homescripts Mail Order Pharmacy

English 550kB   11/29/17

En Español (Spanish) 627kB   11/29/17


Medication Therapy Management

Personal Medication List

English 594kB   12/13/16


Over-the-Counter Benefits

Over-the-Counter Benefits Brochure

English 1.4MB   01/30/18


Prescription Claims

Prescription Drug Claim Form (Medicare Members)

English 113kB   10/23/17


Prescription Drug Claim Form (Commercial Members)

English 3.2MB   09/29/17

En Español (Spanish) 3.2MB   09/29/17


Prescription Transition Form

Prescription Transition Form (Commercial Members)

English 484kB   09/29/17

En Español (Spanish) 485kB   09/29/17



Information last updated 04-23-2018

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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This Schedule of Benefits is a brief list of benefits, with applicable copayments, coinsurance and deductibles information for your health plan. It does not list the exclusions and limitations or other important terms applicable to your plan.

For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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New Year, New Website for You!


Your Health Net Coverage for 2018 comes complete with a brand-new website. The design and menus are easier to navigate. And it's packed with helpful information about your plan, your network and all the extras that come with your coverage.