| |
Crystal HDHP 100% Plans
|
|
In-Network
|
Out of Network
|
Deductible Choices
The deductible Coverage Year (CY) is January 1 through December 31 |
Individual: $2,000, or $5,000 (1)
|
Individual: $4,000, or $10,000 (1)
|
|
Family: $4,000, or $10,000 (1)
|
Family: $8,000, or $20,000 (1)
|
| Lifetime maximum |
$2,000,000 combined
|
| Out-of-pocket maximum (OPM)
|
Individual
|
Same as deductible (2)
|
2 x deductible (2)
|
Family
|
Same as deductible (2)
|
2 x deductible (2)
|
| Professional Services |
| Office visit |
No charge
|
50% UCR+
|
| Well Baby Care (8 exams in the first 24 months) (6) |
No charge
|
50% UCR+
|
Annual OB/GYN exam
(breast and pelvic exams, cervical cancer screening & mammography) (6) |
No charge
|
50% UCR+
|
| X-ray and laboratory procedures |
No charge
|
50% UCR+
|
| Outpatient Services |
| Outpatient or ambulatory care center |
No charge
|
50% UCR+
|
Outpatient rehabilitation therapy
($2,500/year max) |
No charge
|
50% UCR+
|
Outpatient facility services
(other than surgery) |
No charge
|
50% UCR+
|
| Maternity care |
| Physicians services for maternity care |
No charge
|
50% UCR+
|
| Hospitalization services |
| Inpatient hospital care |
No charge
|
50% UCR+
|
Skilled nursing facility care
(60 days per year max) |
No charge
|
50% UCR+
|
Inpatient rehabilitation therapy
(30 days per year max) |
No charge
|
50% UCR+
|
| Emergency health coverage |
| Outpatient emergency room services |
No charge
|
50% UCR+
|
| Inpatient admission from emergency room |
No charge
|
50% UCR+
|
Emergency ambulance
(up to $3,000 per year) |
No charge
|
No charge UCR+
|
| Additional Accident |
| Accidental injury deductible waiver ** |
Not included
|
Prescription Benefit***
Subject to medical deductible |
In Pharmacy
(Per Fill Up to a 30-day Supply)
|
Mail Order
(Per Fill Up to a 90-day Supply)
|
Tier 1 drug list
|
No charge
|
No charge
|
Tier 2 drug list
|
No charge
|
No charge
|
Tier 3 & Specialty
|
You pay 100%***
|
| Preventive benefits |
| Routine physical, prostate screening, vision
screening |
Included
|
|
Notes:
(1) The deductible must be met each calendar year (January 1 through
December 31) before Health Net pays any claims. With this plan, the deductible
applies to the annual out-of-pocket maximum. Family coverage means the
subscriber and spouse; the subscriber and child(ren); or the subscriber,
spouse and child(ren). Under family coverage, each member’s covered
expenses count toward the deductible, but the specified family coverage
deductible must be met before Health Net pays any claims.
(2) The annual out-of-pocket maximum (OPM) is included the annual deductible.
(6) The CY deductible is waived
PRESCRIPTION DRUG PROGRAM
*** In Pharmacy: Prescription drugs may be filled at a participating
pharmacy (up to a 30-day supply). Mail Order: Prescription drugs may
be filled through our participating mail pharmacy (up to a 90-day supply).
When Tier 3 brand name drugs are not covered, members will still have
the advantage of Health Net's pharmacy discounts..
Refer to your contract for details, limitations and exclusions.
|
Plan Updates 
