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Summary of Benefits and Coverage: Coverage ... - …

Summary of Benefits and Coverage : What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 health Net of CA: HMO Coverage for: All Covered Members | Plan Type: HMO (07/26/17) 1 of 6 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a Summary .

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

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Transcription of Summary of Benefits and Coverage: Coverage ... - …

1 Summary of Benefits and Coverage : What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 health Net of CA: HMO Coverage for: All Covered Members | Plan Type: HMO (07/26/17) 1 of 6 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a Summary .

2 For more information about your Coverage , or to get a copy of the complete terms of Coverage , visit or call 1-800-522-0088. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or or you can call 1-800-522-0088 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $0. See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? There is no deductible. There is no deductible. Are there other deductibles for specific services?

3 No. You don t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,985 member / $5,970 family per calendar year. The out-of-pocket limit is the most you could pay in a year for covered services. If you have family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, prescription drugs and health care this plan doesn t cover. Even though you pay these expenses, they don t count toward the out of pocket limit. Will you pay less if you use a network provider? Yes. For a list of preferred providers, see or call 1-800-522-0088.

4 This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Yes. Requires written prior authorization. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

5 2 of 6 * For more information about limitations and exceptions, see the plan or policy document at All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness $25/visit Not covered none Specialist visit $25/visit Not covered Requires prior authorization.

6 Preventive care/screening/ immunization No charge Not covered You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge Not covered Requires referral. Imaging (CT/PET scans, MRIs) $140/procedure Not covered Requires prior authorization. If you need drugs to treat your illness or condition More information about prescription drug Coverage is available at Generic drugs Covered through CVS Caremark Covered through CVS Caremark Contact your plan administrator; Pharmacy Coverage is carved out to CVS Caremark for both pharmacy based and mail order drugs.

7 Preferred brand drugs Covered through CVS Caremark Covered through CVS Caremark Non-preferred brand drugs Covered through CVS Caremark Covered through CVS Caremark Specialty drugs Covered through CVS Caremark Covered through CVS Caremark Contact your plan administrator; Pharmacy Coverage is carved out to CVS Caremark for both pharmacy based and mail order drugs. If you have outpatient surgery Facility fee ( , ambulatory surgery center) $140/procedure Not covered Requires prior authorization. Physician/surgeon fees No charge Not covered none 3 of 6 * For more information about limitations and exceptions, see the plan or policy document at Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-network Provider (You will pay the least) Out-of-Network Provider (You will pay the most)

8 If you need immediate medical attention Emergency room care $210/visit $210/visit Copay waived if admitted to the hospital. Emergency medical transportation No charge No charge none Urgent care $35/visit $35/visit Copay waived if admitted to the hospital. If you have a hospital stay Facility fee ( , hospital room) $340/stay Not covered Requires prior authorization. Physician/surgeon fees No charge Not covered none If you need mental health , behavioral health , or substance abuse services Outpatient services Office visit $25/visit-individual therapy session $ therapy session; Other than office visit- No charge Not covered Prior authorization required except for office visits.

9 Inpatient services $340/stay Not covered Requires prior authorization. If you are pregnant Office visits No charge Not covered Cost sharing does not apply to preventive services. Childbirth/delivery professional services No charge Not covered none Childbirth/delivery facility services $340/stay Not covered none If you need help recovering or have other special health needs Home health care No charge Not covered Limited to 100 visits max per calendar year. Requires prior authorization. Rehabilitation services $25/visit Not covered Requires prior authorization. Habilitation services Not covered Not covered none Skilled nursing care $340/stay Not covered Limited to 100 days per calendar year.

10 Requires prior authorization. Durable medical equipment No charge Not covered Corrective footwear is not covered. Requires prior authorization. Hospice services No charge Not covered Requires prior authorization. 4 of 6 * For more information about limitations and exceptions, see the plan or policy document at Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If your child needs dental or eye care Children s eye exam No charge Not covered Covered through age 17.


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