PureCare One EPO is available through Covered CA in Contra Costa, Marin, Merced, Napa, San Francisco, San Joaquin, San Mateo, Santa Cruz, Solano, Sonoma, Stanislaus, and Tulare counties. Plan Overview Health Net Bronze 60 EPO California Individual & Family Plans THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT AND EVIDENCE OF COVERAGE (EOC) SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.The copayment amounts listed below are the fees charged to you for covered services you receive. Copayments can be either a fixed dollar amount or a percentage of Health Net’s cost for the service or supply and is agreed to in advance by Health Net and the contracted provider. Fixed dollar copayments are due and payable at the time services are rendered. Percentage copayments are usually billed after the service is received.
This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage. 1In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by the Exchange and regardless of income, have no cost- sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost- sharing means copayments, including coinsurance and deductibles. 2Copayments 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. 3Visits 1–3 (combined between office visits, specialist office visit, urgent care, prenatal and postnatal visits, acupuncture, outpatient mental health/substance abuse): The calendar year deductible is waived. Visits 4–unlimited: The calendar year deductible applies. 4Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 5After the medical deductible has been reached, the member is responsible for 100% of the eligible charges until their out-of-pocket maximum limit is met. 6After the pharmacy deductible has been reached, the member will be responsible for 100% of the cost of all Tier 1, 2, 3, and 4 drugs up to a maximum payment of $500 for each prescription of up to a 30-day supply, until the out-of-pocket maximum limit is met. 7The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com. 8Pediatric dental and vision are included on all plans. 9The pediatric dental benefits are underwritten by Health Net Life Insurance Company and administered by Dental Benefit Providers, Inc., dba Dental Benefit Administrative Services (DBP Entities). DBP entities are not affiliated with Health Net. See policy for pediatric dental benefit details. 10The pediatric vision services benefits are underwritten by Health Net Life Insurance Company. Health Net contracts with EyeMed Vision Care, LLC, a vision services provider panel, to administer the pediatric vision services benefits. Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net:
If you need these services, contact Health Net’s Customer Contact Center at 1-888-926-4988 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a grievance by mail: Health Net of California, Inc., PO Box 10348, Van Nuys, California 91410-0348, by fax: 1-877-831-6019, or online: healthnet.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Health Net EPO insurance plans, Policy Form # P34401, are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. Covered California is a registered trademark of the State of California. All rights reserved. FLY008485EH00 (1/17) |