| Benefits Coodinated by your PCP |
Pearl 25 HMO
|
Deductible Choices
The deductible Coverage Year (CY) is January 1 through December 31 |
No Deductible
|
| Out-of-pocket maximum (OPM) |
|
Individual
|
$4,000 single (3)
|
Family
|
$12,000 family (3)
|
| Lifetime maximum |
Unlimited
|
| Professional Services |
| Office visit |
$25
|
| Well Baby Care (8 exams in the first 24 months) |
$25
|
Annual OB/GYN exam
(breast and pelvic exams, cervical cancer screening & mammography) |
$25
|
| X-ray and laboratory procedures |
$25
|
| Outpatient Services |
| Outpatient or ambulatory care center |
$250
|
| Outpatient rehabilitation therapy |
$10
($2,500/year max)
|
Outpatient facility services
(other than surgery) |
$250
|
Maternity care
(Physicians services for maternity care) |
$250 per pregnancy
|
| Hospitalization services |
| Inpatient hospital care |
$400 per day
(until OPM met)
|
Skilled nursing facility care
(60 days/year max)
|
No charge
|
Inpatient rehabilitation therapy
(30 days/year max) |
$400 per day
|
| Emergency services |
| Outpatient emergency room services |
$100 per visit
(waived if admitted)
|
| Inpatient admission from emergency room |
$400 per day
|
| Emergency ambulance transport - $3,000/year
max |
20% (UCR plus applies to Out-of-Network providers)
|
| Additional Accident |
| Accidental injury deductible waiver ** |
No deductible
|
Prescription Benefit
Calendar Year Deductible for Rx Benefits: $100 per Member
Maximum Rx Benefit: $4,000 per Member per Calendar Year |
In Pharmacy
(Per Fill Up to a 30-day Supply)
|
Mail Order
(Per Fill Up to a 90-day Supply)
|
Tier 1
|
50%
|
50%
|
Tier 2
|
50%
|
50%
|
Tier 3
|
You pay the full cost of the prescription at Health
Net’s discounted rate.
|
You pay the full cost of the prescription at Health
Net’s discounted rate.
|
| Preventive benefits |
| Routine physical, prostate screening, vision
screening |
Preventive included
|
Well Net Complementary Care
$500 annual benefit |
Well Net Included
|
| Chiro, acupuncture, naturopathy |
$20 copay
|
| Massage therapy |
$25 copay / 9 visits
|
|
Notes:
You do not have to pay a deductible for medical coverage on the HMO
plan. Prescription drug coverage has a deductible and annual maximum.
Your benefits are subject to copayments listed in this schedule. You must
select a Primary Care Provider (PCP) from our HMO network. Your PCP coordinates
all your health care, including referrals. Certain services are covered
only if provided by a designated Specialty Care provider.
3) After you reach the OPM copayment maximum in a Calendar Year, we will
pay your covered HMO services during the rest of that Calendar Year at
100% of our HMO contract rates.
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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