Health Net


CHARTER/POS 20/500 PLAN (for groups of 2 - 50 employees) This is only one plan of many... please call us for prices
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Deductible single family Coinsurance Max. out of pocket - single family Lifetime Benefit Pre-Existing Condition Exclusion	None None None Not applicable Not applicable Unlimited None	$1,000 $2,000 70/30% $4000 (including deductible) $8,000 (including deductible) $1,000,000 None
Preventive Care Physical Exams (immunizations) Routine Pediatric Care Well woman visits,Pap Tests Mammograms:Screening and Diagnostic	$20.00 co pay No charge children thru age 18 $20 copay - pap smear and two pelvic exams per calendar year No charge for mamograms	Routine Preventive Care (including immunizations) not covered for adults Preventive Pediatric care To age 19 is subject to deductible and coinsurance well woman and mamograms are subject to deductible & coinsurance
Outpatient care Physician office visits Surgery Laboratory services,x-rays	$20 copay per visit $75 co pay No charge	Subject to deductible & coinsurance Subject to deductible & coinsurance&* Subject to deductible & coinsurance
Allergy Care	$20 co pay	Subject to deductible & coinsurance**
Hospital Care Physicians & surgeon services Semi private room & board All drugs & medication	$500 co pay per adnission per 90 day benefit period***	Subject to deductible & coinsurance & *
Emergency Care Doctor visit Urgent care at an Urgent Care Center Hospital Emergency Room	$20 per visit $25 copay $50 copay	$20 per visit $25 copay $50 copay
Maternity Care Prenatal & Post-natal care Hospital services for mother & child	No charge $500 co pay	Subject to deductible & coinsurance ** Subject to deductible & coinsurance
Short Term Rehabilitation Physical and Occupational Therapy Speech therapy ( 90 consecutive days )	$20 Copay per visit Up to 30 visits per year $20 per visit	Subject to deductible & coinsurance &* Up to 30 visits per year Subject to deductible and coinsurance** (90 con. days)
Home Health Care 0r Hospice when skilled services are required Inpatient Hospice care	No charge* $500 copay per admission per 90 day benefit period*	Subject to deductible and 50% coinsurance&* Subject to deductible and coinsurance&*
Inpatient Skilled Services Such as Physical and Occupational Therapy and Skilled Nursing 90 days per calendar year	$500 co pay per admission per 90 day benefit period***	Subject to deductible & coinsurance&*
Substance abuse Outpatient - 60 days per calendar year (20 of these visits may be used for covered family members) Inpatient diagnosis & medical treatment for drug and alcohol abuse Inpatient rehab tratment for the abuse of or addiction to drugs and alcohol - 30 days per calendar year	$20 per visit $500 copay per admission per 90 day benefit period* $500 copay per admission per 90 day benefit period*	Subject to deductible & coinsurance&*
Mental Health Care 30 Inpatient days,( exchangeable for 60 partial hospitalization sessions per year) 20 Outpatient visits per cal. year (medically necessary visits beyond visit #6 must be approved in advance by PHS)	$500 copay per admission per 90 day benefit period*.$75 copay for the first day in a partial day program* $20 copay per visit****	Subject to deductible & coinsurance&* Subject to deductible & 50% coinsurance&* 20 Outpatient visits per cal. year
Prescription Drugs $2,000 Maximum annually	$15/generic-$25/preferred/$40/non preferred Mail Order is twice the copay 90 day supply	Same as in Network
Chiropractic Care	$20 Copay per visit	Subject to deductible & coinsurance&* all visits after 15 require advance approval.
Infertility Treatment and Family Planning (Excludes in-vitro fertilization,GIFT and ZIFT) Office visits	$20 Copay per visit	All subject to deductible & Coinsurance**
Vision Care - routine eye exams, including refractions: Annually up to age 19 Adults - once every 2 calendar year Medical eye injury or illness	All at $20 copay	Routine eye exams are not covered Injury and illness are subject to deductibles and coinsurance**
Other Coverages Durable Equipment (Certain devices require prior authorization)	PHS pays 50% of the cost of covered items, up to the combined in and out of network maximum of $1,500 per year.	See in network
Acupuncture (20 visits per calendar year)	$20 copay per visit*	In network only
Prosthetics (Maximums are combined for both in and out of network) Internal External, to a max of $5,000 for the first appliance	No cost* (External)No cost***	Subject to deductible & Coimsurance&*

* - In network services and benefits provided or arranged by a PHS participating provider.

** - Out of network services require a member to pay a deductible and coinsurance.

*** - When medically necessary and approved in advance by the PHS Medical Director

**** - Allowed amount is based on vendor fee schedule

Conditions and Limitations: You are covered for emergencies anywhere in the world. If the situation is life threatening, go straight to the nearest hospital's emergency room or call 911. If at all possible, try to reach your PHS primary care physician. Please be sure it is a true emergency. Many people go to the emergency room for things like colds, sore throats,coughs and routine fevers because it is convenient. While none of these problems constitutes an emergency, you are covered for all of them through a visit to your physician's office. You will be responsible for emergency room charges when it is not an emergency.

Out of Network Benefits: When using out of network benefits, prior autorization is required for all in- patient and out patient hospital admissions, all elective ambulatory surgical procedures and most diagnostic procedures performed in a non-plan hospital or free-standing surgical center. To obtain prior authorization, please contact PHS' Customer Service Department at 1-800-441-5741. A penalty is applied to out-of-network reimbursement when the member does not complete the prior authorization process.

General Exclusions: You are not covered for physical exams for employment, insurance, school, premarital requirement or summer camp (unless submitted for a normal physical exam); prescription drugs and some injectible dispensed by a physician in his or her office; prescription drugs prescribed for a non-covered service; dental services unless provided by a rider to the PHS Subscriber Contract; eyeglasses or contact lenses unless provided by a rider to the PHS Subscriber Contract; hearing aids: routine foot care; foot orthotics; some transplant procedures; cosmetic or reconstructive surgery, unless medically necessary; custodial services; weight-reduction programs;marraige counseling; or long term psychiatric treatment.

PHS will not duplicate any benefits for which members are entitled under worker's compensation, No-Fault,Medicare, or other group health insurance coverage. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The PHS Subscriber Contract is the final arbiter of coverage under PHS. If you have any questions, please call the PHS Customer Service Department at 1-800-441-5741. Benefits are subject to Department of Insurance approval.