Download IFP Plans_022004

Schedule of covered services (Continued)
Benefit description
Other services
Rehabilitative therapy includes physical, speech,
occupational, respiratory and cardiac therapy 5
Chiropractic care (12-visit calendar year maximum)
Mental health services for severe conditions 5,7 8,9
Mental health for non-severe conditions5,7,8,10
Durable medical equipment (including foot
orthotics)
Outpatient prescription drugs 11,12
Filled at participating pharmacy (up to a 30-day
supply); not covered at non-participating
pharmacies, Filled through mail order (up to a 90day supply) Twice the Level copayment
1.
2.
PPO Value Basic 35
In-Network 1
Out-of-Network 2
Negotiated fee until out-of-pocket
maximum is met, then covered in
full.
No benefits until out-of-pocket
maximum met, then covered in
full
20 visit maximum per calendar year
Not covered
Not covered
$350 + 35% inpatient / 35%
$350 + 50% inpatient / 50%
Outpatient
Outpatient
$350 + 35% inpatient/ Negotiated
fee until out-of-pocket maximum
is met, then covered in full out
patient
$350 + 50% inpatient / not
covered outpatient
50% ($500 calendar year max.)
Not Covered
$15 Copay (Generic Only)
Not covered
Of negotiated rate, the rate the Participating or Preferred Provider has agreed to accept for providing a covered service.
Percentage is a portion of the covered expense based on (C& R) Customary & Reasonable. You are also responsible for any charges in
excess of the covered expense.
3. Mammograms are covered at the following intervals: One for ages 35-39, one every 24 months for ages 40-49, and one every year for age
50 and older.
4. The emergency room and urgent care copay are waived if admitted to the hospital for an emergency. The emergency room and urgent
care copay are per visit and do not apply to the out-of-pocket maximum. The calendar year deductible applies to emergency room visits.
5. Certain services require prior certification from Health Net. Without prior certification, benefit reduced by 50%.
6. Maximum Allowable charges are $600 per day.
7. Covered expenses incurred for non-severe mental illness and chemical dependency do not apply to the out-of-pocket maximum.
8. The inpatient/outpatient copay applies to the OOP accumulation and continues to apply once the out-of-pocket maximum is met.
9. The following are considered severe mental illness: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders,
panic disorders, obsessive-compulsive disorder, pervasive development disorder or autism, anorexia nervosa, serious emotional
disturbances in children under age 18.
10. Non-severe mental illness inpatient maximum payable per day is $300, benefit maximum is 30 days; if covered by the plan, outpatient
non-severe mental illness is $30 maximum payable per visit, 20 visits maximum per year.
11. Generic Drugs which are not listed on the Recommended Drug List and Brand Name Drugs are not covered. The Recommended Drug List is
a list of the prescription drugs that are covered by this plan. It is prepared by Health Net and given to member physicians and
participating pharmacies. Some drugs require prior authorization from Health Net. Also, if your condition requires the use of a drug that
is not in the Recommended Drug List, your physician may require the drug through the prior authorization process. Urgent prior
authorization requests are handled within 72 hours. For a copy of the Recommended Drug List, call Member Services at the number listed
on your ID card or visit our web site at www.healthnet.com. Prescription drug charges do not apply to your maximum out-of-pocket limit.
12. Medical calendar year deductible waived.
EFFECTIVE OCTOBER 1, 2004
HEALTH NET LIFE INSURANCE COMPANY
INDIVIDUAL & FAMILY PLAN PPO PLANS
Principal benefits and coverage matrix — PPO
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND
IS A SUMMARY ONLY. THE POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION
OF COVERAGE BENEFITS AND LIMITATIONS.
Benefit Description
Value Basic 1500
1
In-Network Provider
Annual deductible (subscriber only plan)
Annual out-of-pocket maximum
Lifetime Maximum
Visit to physician
3
X-ray and laboratory procedures
$1,500
$4,000 combined in-network and out-of-network (includes
deductible)
$6 million
Negotiated fee until OOPM is No benefits until OOPM is met,
met, then covered in full
then covered in full
Negotiated fee until OOPM is No benefits until OOPM is met,
met, then covered in full
then covered in full
Preventive care
Routine physical exams, including routine lab
and X-ray services
Annual OB/GYN exam (breast and pelvic
exams, cervical cancer screening and
4
mammography)
Prostate cancer screening and exam
Immunizations Standard
To meet foreign travel or occupational
requirements
Child preventive care (1 to age 18); checkups,
vision and hearing exams
Child preventive care
Immunizations
Allergy testing and injection services
Not covered
25%
Alcohol detoxification
7
Not covered
25%
Not covered
Not covered
Not covered
25%
Not covered
25%
Not covered
Negotiated fee until OOPM is
met, then covered in full
No benefits until OOPM is met,
then covered in full
Maternity and pregnancy
Prenatal and postnatal office visits
Maternity care in hospital
Emergency and urgent care
Emergency room (professional and facility
charges)
Urgent care center (facility charges)
3
Ambulance
3
Inpatient Hospital services (non-emergency care)
Physician/surgeon and anesthetics services
Organ and bone marrow transplants
(nonexperimental and noninvestigational)
2
Out-of-Network Provider
Not covered
Not covered
25%
25%
25%
25%
25%
25%
25%
50%
25%
Not covered
25%
50%
5
3 days per calendar year combined in-and-out-of-network
IFP20040718
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EFFECTIVE OCTOBER 1, 2004
HEALTH NET LIFE INSURANCE COMPANY
INDIVIDUAL & FAMILY PLAN PPO PLANS
Summary of Benefits continued
Benefit Description
Value Basic 1500
1
In-Network Provider
2
Out-of-Network Provider
3
Hospital and skilled nursing facility (facility charges)
5
Inpatient, semiprivate hospital room or
25%
50%
intensive care unit with ancillary services
(unlimited, except for mental health and
substance abuse treatment)
5
Outpatient surgery
25%
50%
5
Skilled nursing facility
25%
50%
(100-day annual limit combined
in- and out-of-network)
Reproductive health
Sterilization
25%
not covered
Other services
Home health services (limited to 60 visits per
25%
50%, $75 maximum payable per
calendar year combined in- and out-ofday
3
network)
3
Hospice services
25%
50%
Rehabilitative therapy (includes physical,
Negotiated fee until OOPM is
No benefits until OOPM is met,
speech, occupational, respiratory and
met, then covered in full
then covered in full
3
cardiac therapy)
Limited to 20 visits per calendar year combined in- and out-ofnetwork
Chiropractic care
Not covered
Acupuncture
Not covered
5
Mental health services for severe conditions
25% Inpatient / Negotiated fee
50% inpatient / No benefits until
until OOPM is met Outpatient
OOPM is met then covered in full
then covered in full
Outpatient
Mental health services for nonsevere
6,7
conditions
1
2
3
4
5
6
7
8
25% Inpatient / Negotiated fee
until OOPM is met then covered
in full Outpatient
Durable medical equipment (including foot
50%
3
orthotics)
($500 Calendar year max)
Corrective footwear ($200 maximum payable
50%
3
per calendar year)
3
Prosthetics and corrective appliances
25%
8
Outpatient prescription drugs
Filled at participating pharmacy (up to a 30$15 copay (generic only)
day supply); not covered at non-participating
pharmacies, Filled through mail order (up to
a 90-day supply) Twice the Level
copayment
50% inpatient/ not covered
outpatient
Not covered
Not covered
50%
Not covered
Of negotiated rate, the rate the Participating or Preferred Provider has agreed to accept for providing a covered service.
Percentage is a portion of the covered expense based on (C&R) Customary & Reasonable. You are also responsible for any charges in excess of the covered expense.
Certain services require prior certification from Health Net. Without prior certification, benefit reduced by 50%.
One mammogram for ages 35-39, one every 24 months for ages 40-49, and one every year for age 50 and older.
Allowable charges are $600 per day.
Treatment of non-severe mental disorders is limited to Participating or Preferred Providers for outpatient services, with the following maximums: 20 outpatient visits, $30
maximum payable per outpatient visit; 30 inpatient days per calendar year; and a maximum allowable limit per day for inpatient services of $300.
Covered expenses incurred for non-severe mental illness and chemical dependency do not apply to the out-of-pocket maximum.
Generic Drugs which are not listed on the Recommended Drug List and Brand Name Drugs are not covered. The Recommended Drug List is a list of the prescription
drugs that are covered by this plan. It is prepared by Health Net and given to member physicians and participating pharmacies. Some drugs require prior authorization
from Health Net. Also, if your condition requires the use of a drug that is not in the Recommended Drug List, your physician may require the drug through the prior
authorization process. Urgent prior authorization requests are handled within 72 hours. For a copy of the Recommended Drug List, call Member Services at the number
listed on your ID card or visit our web site at www.healthnet.com. Prescription drug charges do not apply to your maximum out-of-pocket limit.
IFP20040718
r