| |
Diamond 15 Plan |
|
In-Network |
Out of Network |
Deductible Choices
The deductible Coverage Year (CY) is January 1 through December 31 |
Individual: $250, $500, $1,000, $2,500, $5,000, or $7,500
(4,5) |
|
Family = 3x Individual |
| Lifetime maximum |
$2,000,000 combined |
| Out-of-pocket maximum (OPM) |
|
Individual
|
$4,000 (7) |
$8,000 (7) |
Family
|
$12,000 (7) |
$24,000 (7) |
| Professional Services |
| Office visit |
$15 (6) |
50% UCR+ |
| Well Baby Care (8 exams in the first 24 months) (6) |
$15 (6) |
50% UCR+ |
Annual OB/GYN exam
(breast and pelvic exams, cervical cancer screening & mammography) (6) |
$15 (6) |
50% UCR+ |
| X-ray and laboratory procedures |
20% |
50% UCR+ |
| Outpatient Services |
| Outpatient or ambulatory care center |
20% |
50% UCR+ |
Outpatient rehabilitation therapy
($2,500/year max) |
20% |
50% UCR+ |
Outpatient facility services
(other than surgery) |
20% |
50% UCR+ |
| Maternity care |
| Physicians services for maternity care |
20% |
50% UCR+ |
| Hospitalization services |
| Inpatient hospital care |
20% |
50% UCR+ |
Skilled nursing facility care
(60 days per year max) |
20% |
50% UCR+ |
Inpatient rehabilitation therapy
(30 days per year max) |
20% |
50% UCR+ |
| Emergency health coverage |
| Outpatient emergency room services |
20% |
50% UCR+ |
| Inpatient admission from emergency room |
20% |
50% UCR+ |
Emergency ambulance
(up to $3,000 per year) |
20% |
20% UCR+ |
| Additional Accident |
| Accidental injury deductible waiver ** |
20%
(Deductible waived) |
20% UCR+
(Deductible waived) |
Prescription Benefit***
$100 Rx deductible; up to $4,000 per year |
In Pharmacy
(Per Fill Up to a 30-day Supply) |
Mail Order
(Per Fill Up to a 90-day Supply) |
Tier 1 drug list
|
50% |
50% |
Tier 2 drug list
|
50% |
50% |
Tier 3 & Specialty
|
You pay 100%*** |
| Preventive benefits |
| Routine physical, prostate screening, vision
screening (6) |
Well Net included |
Well Net Complementary Care
$500 annual benefit (6) |
Chiro, acupuncture, naturopathy
|
$20 copay |
Massage Therapy
|
$25 copay / 9 visits |
|
Notes:
Well Net complementary care program provides services through ASH provider
network, and is not subject to a deductible.
The CY deductible for PPO plans is waived for services requiring a copayment
and for covered preventive care benefits. Copayments do not apply toward
your OPM.
**Diamond 15, Topaz First Dollar, and Emerald 40 plans include an Additional
Accident benefit. The Calendar Year deductible may be waived for treatment
of accidental injury in an Emergency Room (ER) or Urgent Care (UR) facility.
ER or UR copays or coinsurance will still apply and follow up treatment
is subject to Plan benefits. The Waiver Request form is available through
Customer Service, and must be filed within 90 days of the injury.
(4) Unless otherwise specified, you must meet the Calendar Year deductible
before Health Net pays any claims.
(5) Your deductible payments do not apply to the annual out-of-pocket
maximum.
(6) The CY deductible is waived
(7) The annual out-of-pocket maximum does not include the annual deductible.
After you reach the out-of-pocket maximum in a calendar year, we will
pay your covered services during the rest of that calendar year at 100%
of our contract rates for PPO services and at 100% of UCR for out-of-network
(OON) services. You are still responsible for OON billed charges that
exceed UCR.
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. |
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