Affordable Health Coverage Is Here! We Are Your Health Net

OUTSIDE

Individual & Family Plans Covered California Get your affordable health coverage Central and Northern California

Call Health Net at 1-877-609-8711.

✔ We will help you look at your choices.

✔ We can tell you if you can qualify for low-cost or no-cost health coverage.

✔ We can help you sign up. Or we can connect you with a broker or a Covered California

Certified Enrollment Counselor. ______Traffic: Print Prod.: ______Print Prod.: : ______e t a We are your Health Net. er d CS Mgr: ______hure/fol c bro s ______D ______le : t a n S Mktg. Lead: ______Client: ______pri FB

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coverage is here! r Job Ti R ____ R d N Covered California open enrollment began October 1, 2013.

E Job#: 6029262_CA104497_fl Z I S E CS

Before you choose, let us be your guide to: E Forms: 10 pt _____ □ Health Net SP Size: 24.25 x 12” Colors: cvr: 4/? (4c pro/?) / guts: 4/4 cmyk Finished: 9 x 12” with 1/4” spine and 5-3/4” vertical pocket with 3/16” capacity (job can use same die as 6026837) TYP Health coverage basics • Health Net plans • Important facts PO Box 1150

Rancho Cordova, CA 95741-1150 Time: 4:36 PM 1-877-609-8711 sts

Assistance for the hearing and speech impaired i t Comment-enabled PDF Slug specs = Ticket

1-800-995-0852 Date: 09/24/13 Ar □ I have proofed □ □ ______ARTIST:

www.healthnet.com

6029262 CA104497 (1/14) Health Net PPO insurance plans, Policy Form # P30601, are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. Covered California is a registered trademark of the State of California. All rights reserved.

9x12 w/a 1/4” capacity at spine and a 3/16” capacity pocket

dashed line is fpo for scores for folding—do not print Welcome to Health Net!

If you don’t have health coverage, you are not alone. Maybe your job doesn’t offer it. Or maybe your health has made it hard to get. For millions of people, it has not been affordable.

That’s all changing!

You may have heard about health care reform. The law is called the Affordable Care Act. Some people refer to it as Obamacare.

The goal is to make health coverage easier to get and more affordable. California’s new health care marketplace, called Covered CaliforniaTM, is one of the ways to help you do that.

Health Net is part of Covered California. We want to help you find the coverage that is right for you. We made this guide to help you do that. Plus, we have important facts about Health Net’s health coverage in the back pocket.

What you’ll find inside…

Health coverage basics We are your Health Net The new health insurance Coverage at an affordable cost . . . . 12 marketplace ...... 4 What kind of coverage fits you? . . . . 12 Who can buy ...... 5. Health Net PPO plans ...... 14 What you can buy ...... 5 How to find a doctor ...... 16 When to sign up ...... 6 More reasons why we are your Penalties if you do not have Health Net ...... 18 Sometimes it seems like health coverage ...... 6 Health coverage dictionary ...... 20 health coverage comes with Costs and financial help ...... 7 its own language! We have a

Premium assistance ...... 9 mini-dictionary at the back of

Cost-sharing reductions ...... 9 this book. Turn to page 20 if you

come across a term you don’t

know as you read this guide and

consider your choices. Health coverage basics Health coverage is changing in 2014. You will be able to compare and buy health coverage through Covered California. You might get help paying for it.

Health Net wants to help you get the most from all the changes. Our “health coverage basics” walks you through it all. You can call us for help at 1-877-609-8711.

3 Health Insurance MARKETPLACE

A new way to shop for health coverage

Covered California is a health insurance marketplace. It is a new way you can shop for affordable, high-quality health coverage online.

Health coverage helps pay for major expenses that can add up if you get sick or injured. It covers care that helps you stay healthy with checkups, vaccines and health screenings. It also helps cover the cost of prescription drugs.

When you have health coverage, you have help when you need it most.

Covered California opened on October 1, 2013. You can buy now for health coverage that will take effect in 2014. Health Net can help you sign up through Covered California. Call us at 1-877-609-8711 today!

4 Who can buy

People who can buy health coverage through Covered California are those who are: • a California resident,

• a U .S . citizen/national,

• lawfully present in the U .S ., and

• not incarcerated .

• Y our spouse or domestic partner, if under age 65, and your children up to age 26 are also eligible to enroll as dependents .

People can apply and purchase coverage during an open enrollment period or during a special enrollment period. If you are age 65 or over, you may be eligible for Medicare.

What you can buy

• You can buy a health plan. You will have All companies offer the same standard benefits that include: standard benefits on each level . – Doctor visits, hospital services, newborn So . . care, and prescription drugs. – Preventive care and medical screenings. A mammogram is one example. So is the test for colon cancer. There is no cost to = you for these services. • You have your choice from different companies. Silver plan from Silver plan from Company A Company B • You cannot be denied coverage even if you have a medical condition. The plans come in four “metal” levels: That makes it easy to compare .

Platinum Gold Silver Bronze

Covered California also has a minimum coverage option. It is a high-deductible health plan with lower monthly premiums.

5 When to sign up

You can sign up for coverage during open enrollment. Open enrollment for 2014 starts on October 1, 2013. The initial open enrollment period ends March 31, 2014.

If you sign up… Your health plan starts… On or before December 15, 2013 January 1, 2014. Example: Sign up on November 8 and your coverage will start January 1, 2014. Between the 1st and 15th of the month The first day of the following month. Example: Sign up on January 10, 2014, and your coverage will start February 1, 2014. Between the 16th and last day of The first day of the second following month. the month Example: Sign up on January 20, 2014, and your coverage will start March 1, 2014.

Penalties if you do not have health coverage

Most American U.S. citizens, U.S. nationals and resident aliens have to be enrolled in a health In 2014, the penalty insurance plan that for a single person is meets minimum essential coverage. People currently insured through an employer or a $95 or 1% plan they bought on their own likely meet the of income requirement already. So do those enrolled in a – whichever is more . Medicare plan, TRICARE, Medicaid, and a few other programs.

People who are required to have health insurance but choose not to buy it have to pay a penalty when filing their taxes. There are a few exceptions. You can learn about these exceptions at www.coveredca.com.

6 Costs and financial help

Health coverage levels and costs There are two parts to what you pay.

Monthly premium Copayment or You might have a third part to 1 2 coinsurance pay . It is called a deductible . Some types of health coverage This is the cost This is your Bill have a deductible . This is the $$$ you pay every share of costs month whether you pay when amount you owe for some covered or not you use you use health health care services before your services . services . health plan begins to pay .

How much you pay in premiums and copayments depends on the health coverage level you choose. This chart shows you how it works.

What you pay vs. what the health coverage company pays Each of the four metal levels is based on the total average costs for benefits that a plan covers . That means a platinum plan will cover the most when you use services . The trade-off is the premium will be higher .

Platinum Gold Silver Bronze

10% 20% 30% 40% = You

= Health coverage company 90% 80% 70% 60%

Highest % of costs paid by health plan Lowest

Lowest Your out-of-pocket costs for services Highest

Minimum coverage option Covered California offers a minimum coverage option for people under the age of 30 . It is also an option for people having 50% 50% financial hardship . It is a high-deductible health plan with a lower monthly premium . People who have this plan have to meet the $6,350 deductible first . Then benefits for covered services are generally 50 percent .

7 Financial help The government is giving financial help to people who qualify. The less income you make, the less you pay. There are two kinds of help:

Premium assistance Cost-sharing Bill Monthly lowers the cost you reductions lower $$$ pay every month for what you pay for $ health care coverage . services like doctor visits .

Both kinds of help are based on your annual household income. It works like this for a single person and for a family of four (these dollar amounts are approximate):

Medi-Cal Cost- Household income Premium (free health sharing You have to buy health (based on the year 2013) assistance insurance reductions program) coverage through Covered

California to get premium Under $15,860 ✔ Single assistance and/or cost- $15,860–$28,725 ✔ ✔ person sharing reductions. $28,725–$45,960 ✔ Under $32,500 ✔ Family $32,500–$58,875 ✔ ✔ of four $58,875–$94,200 ✔

Health Net can help you find out what you will Medi-Cal is California’s Medicaid health pay based on your income and the number of care program. This program provides people in your family. We will also help you free medical services for children and find the coverage level that fits you best. adults with limited income and resources. Call us at 1-877-609-8711. You can get help applying for Medi-Cal through Covered California. Health Net also can help you determine if you are eligible for Medi-Cal.

8 Jane can choose how she wants to apply her A premium assistance. She can: closer 1 Take the entire amount of premium assistance right away to lower her look monthly premium bills. 2 Wait until the end of the year and apply the amount as a credit when filing taxes. Premium assistance 3 Apply some right away, and the balance at tax time. Jane is a 40-year-old single mother with three Income changes during the year will change kids. She earns about $35,000 per year. your assistance level. Let’s say Jane takes her As an example, let’s say her premium is full amount up front. If her income goes $12,336 per year for a silver-level plan. She up, she will have to pay the difference at qualifies for $10,908 in premium assistance. tax time. That is why it is very important to That lowers her yearly premium cost to report any income changes immediately to $1,428. Jane pays about $119 per month. Covered California.

Cost-sharing reductions

Jane’s income level also qualifies her for For example, Jane will pay $3 when she goes cost-sharing reductions. to the doctor instead of $45. That is a lower cost than even a platinum plan. Again, Jane She can get them if she enrolls in a silver- only gets cost-sharing reductions if she level plan. If she does, she will pay less out- signs up for a silver-level plan. of-pocket when she and her children use health care services. Her plan will be called an Enhanced Silver plan.

Jane’s choices and cost trade-offs • Jane’s premium assistance amount could • Jane could get an Enhanced Silver plan mean that she would pay $0 in monthly because she qualifies for cost-sharing premiums for a bronze plan. That might reductions. She will pay a monthly be very attractive. However, she would not premium, but her costs will be a lot lower receive the cost-sharing reductions. when she needs medical care. Bronze plans have a higher deductible than If she goes to the doctor often or needs any other metal level. They only cover 60% ongoing treatment for a condition, an of costs for services used. That means Jane Enhanced Silver plan will probably cost will pay more out-of-pocket. her less overall.

9 We are your Health Net We are one of California’s oldest health plans. We are based in California. We live and work here in the Golden State, just like you.

For decades, people have counted on Health Net companies for affordable, quality health plans.

Now we are part of Covered California. And we hope to be part of your health coverage team. We are here for you at 1-877-609-8711.

11 No-cost and low-cost health coverage – you may qualify! Health Net has you covered.

You deserve health coverage you can count on – one that is affordable and gives you choices. That is where Health Net comes in.

Health Net companies help more than five million people get the health coverage they need. We do this by helping to make it easier to get important health care benefits and services, plus a whole lot more.

Our quality doctor networks help people like you and your family get the care they need through every stage of their lives and health.

First things first … What kind of coverage fits you?

Health Net has an option for you no matter what level of coverage you want. We offer PPO plans in all the metal levels.

If you want this This is the Health Net plan for you: Covered California plan level…

Platinum Health Net PPO Platinum

Gold Health Net PPO Gold

Silver Health Net PPO Silver

Bronze Health Net PPO Bronze

Minimum coverage option Health Net PPO Catastrophic

12 How to choose between Location, location, location coverage levels The right level of coverage for you depends on You can sign up for your health care needs. It also depends on your Health Net if you live . budget and how you like to plan. in any of these places There is a trade-off between the monthly premium and the amount you pay when you need medical care. Sonoma Napa

Solano You can choose: Marin San Contra Joaquin Costa San Francisco Stanislaus Mariposa

San Mateo Santa Merced + Clara Santa Cruz San Benito Lower monthly Higher out-of- premium pocket costs Tulare Monterey

Kern Or: +

Higher monthly Lower out-of- premium pocket costs

So, what kind of coverage fits you?

Read on to find out more

13 Health Net PPO plans

Health Net PPO plans give you a wide range You pay less out-of-pocket when you go to a of health care benefits. You can see a doctor in doctor that is in the Health Net PPO network. Health Net’s big PPO provider network. Or you A PPO is good for people who want extra can visit a doctor outside our network. flexibility.

PPOs are good if How PPO plans work you want…

• Car e without getting a

referral first.

• The choice to see any

doctor and the option to

pay less out-of-pocket

if you go to a doctor

in the network.

You

Inside the network ––– $$

Outside the network ––– $$$$

14 Health Net PPO plans: your share of costs

Benefit Platinum Gold Silver Bronze Catastrophic1 In- Out-of- In- Out-of- In- Out-of- In- Out-of- In- Out-of- network network network network network network network network network network

Deductible For one person / $0 / $0 $0 / $0 $0 / $0 $0 / $0 $2,000 / $4,000 / $5,000 / $10,000 / $6,350 / $12,700 / for family $4,000 $8,000 $10,000 $20,000 $12,700 $25,400

Maximum out-of-pocket For one person / $4,000 / $8,000 / $6,350 / $12,700 / $6,350 / $12,700 / $6,350 / $12,700 / $6,350 / $12,700 / for family $8,000 $16,000 $12,700 $25,400 $12,700 $25,400 $12,700 $25,400 $12,700 $25,400

Doctor $20 50% $30 50% $452 50% $603 50% 0%3 50% office visit

Specialist $40 50% $50 50% $652 50% $70 50% 0% 50%

Hospital stay 10% 50% 20% 50% 20% 50% 30% 50% 0% 50%

Outpatient 10% 50% 20% 50% 20%2 50% 30% 50% 0% 50% surgery

Urgent care $40 50% $60 50% $902 50% $1203 50% 0%3 50%

Emergency care $150 $150 $250 $250 $250 $250 $300 $300 0% $0 Prescription drugs Generic / $5 / Not $19 / Not $19 / Not $19 / Not 0% Not Preferred brand / $15 / covered $50 / covered $50 / covered $50 / covered covered Non-preferred $25 $70 $70 $75 brand

1This plan is for people under the age of 30. It may also be an option for people having financial hardship. You can call us at 1-877-609-8711 to confirm if you are eligible for this plan. 2Your deductible does not apply to these services. 3You get coverage for visits 1–3 before you pay your deductible. You just pay the copayment. For visits 4 and more, you pay the full cost until you have paid your deductible. After that, you pay your copayment. Pediatric vision coverage for children through age 18 is included with our health plans available through Covered California. The deductible applies unless otherwise noted. Some services are only covered if you go to a Health Net PPO network provider. This is a summary only. The PPO insert in the back pocket has plan overviews with more details about what services are covered.

How would a PPO work for our friend Sam? Sam has an injury from playing soccer on the weekend. He wants to see a sports medicine Learn about our doctor networks and specialist. If Sam has a PPO plan, he can see all the extra things Health Net offers. his main doctor first or he can go straight to a sports medicine specialist. He also can Read on choose what specialist he sees. Sam will have lower out-of-pocket costs if he sees a specialist in Health Net’s PPO network. 15 Health Net makes it easy for you to find a doctor. It is important to have a doctor who knows you.

With a Health Net PPO plan, you do not have to pick a primary doctor in our network, but you can. If you do, you will have someone you know when you need health advice or when you are sick. Plus, you pay less for services than if you see a doctor outside our network.

Search our networks Our networks give you many doctor choices. If you have a doctor today, you can find out if he or she is part of our network. You can look for doctors close to where you live or work.

Call Health Net Use the Internet

Call our toll-free phone number and we We also have our network directories online. will help you find a doctor. Our number is You can use a computer to search for doctors. 1-877-609-8711. We are here to talk with you, Monday through Friday, from 8:00 a.m. to 6:00 p.m.

To find a doctor on the Internet: 1 Go to www.healthnet.com. 2 Click on the button that says “ProviderSearch .” Then click on “Search Now .” 3 Enter either an address or the city/state or county, then click “Continue .” 4 Select “Doctors .” 5 Select “PPO .”

16 Doctor visits when you need care. We are your Health Net.

Prescription drug coverage. We are your Health Net.

Flu shots. Mammograms. Vaccines for kids. We are your Health Net.

Medical advice anytime day or night, and on weekends. We are your Health Net.

Urgent care and hospital services when you need them. We are your Health Net.

17 More reasons why Talk to a nurse anytime Health Net is here for your health with we are your Health Net Nurse24. We have licensed nurses available 24/7 by phone or online chat to answer your questions. Our nurses can help you figure out what to do next about:

• caring for minor injuries and illnesses like fevers and the flu, • urgent health situations, • preparing for doctor visits, and • other health questions.

National Accreditation Health Net plans are accredited for quality. You can count on us.

Award-winning Cultural and Linguistics program Health Net received the Multicultural Health Care Distinction from the National Committee for Quality Assurance. This means that no matter where you are from or what language you speak, Health Net will make sure you get access to quality health care that is easy to understand.

18 Get an online account Set up an online account so you can: With Health Net, you also get a free, ✔ Order ID cards . online account. Having an online account ✔ See your plan details . is one way we help you build healthy habits. It is also an easy way to get the information ✔ View pharmacy benefits or find a you need. pharmacist near you .

You can set up your online account after you ✔ Search for a doctor or specialist in sign up for a Health Net health plan. Use your California . computer to go to www.healthnet.com. Start by ✔ Use online programs for weight clicking the pink Members tab. Next, click the management, stopping smoking Register button at the top right of the page. and more .

✔ Learn about health conditions .

✔ Know when to get health screenings .

✔ Email our customer service team .

And much more!

Health Net Mobile Health Net Mobile is an easy way to connect to your HealthNet .com online account . You can get:

• Benefit information.

• A mobile ID card.

• Directions to the doctor’s office.

Available for Apple, Android, Blackberry and other web-enabled devices .

19 Health coverage dictionary

Sometimes it seems like the health insurance industry has its own language! Use our mini-dictionary as you read this guide and consider your choices.

Allowed Amount Cost-Sharing The maximum amount per service that The share of costs covered by your your health plan allows. Your health plan that you pay out of your own plan bases how much it will pay on the pocket. This term generally includes allowed amount. deductibles, coinsurance, copayments, or similar charges. Benefits (also called Covered Services) Deductible The health care items or services that The amount you owe for some covered are covered. health care services before your health plan begins to pay for those services. Coinsurance For example, if your deductible is $1,000, you have to pay for the health Your share of the costs of a covered care services you use up to this amount. health care service, calculated as a The deductible may not apply to all percent (for example, 20%) of the services. allowed amount for the service.

Let’s say the coinsurance is 20% and the Dependents medical bill is $100. You would pay $20, Spouses, children or partners of the and the health plan would pay the rest. main policyholder.

Copayment (also called Copay) Excluded Services A fixed amount you pay for the services Health care services that your health you use. For a doctor visit that might coverage doesn’t pay for or cover. cost $150, you could pay $15 and the health plan pays the rest.

20 Geographic Service Area Policyholder A defined geographic area that a health The term policyholder refers to the plan serves. primary insured person in a PPO plan.

Insured Preferred Provider Organization (PPO) The person who receives benefits under a PPO health insurance plan. A PPO is a type of health insurance. It gives you the choice to go to any doctor Network for most covered services. You do not need a referral. You pay less out-of-pocket The doctors, hospitals, labs, and other if you go to a doctor in the network. health care providers that your health plan has contracted with to provide health Premium care services. The amount you pay every month to have Out-of-Pocket Maximum health coverage. The most you pay during a policy period (usually a year), after which your health coverage begins to pay 100% of the allowed amount for covered services. This limit never includes your premium or health care charges for services your health plan doesn’t cover.

21 OUTSIDE

Individual & Family Plans Covered California Get your affordable health coverage Central and Northern California

Call Health Net at 1-877-609-8711.

✔ We will help you look at your choices.

✔ We can tell you if you can qualify for low-cost or no-cost health coverage.

✔ We can help you sign up. Or we can connect you with a broker or a Covered California

o /C

O l a v P PP o S IF L pr p VA le: Writer: ______Writer: A t

Affordable health l RO a n i Design Mgr: ______APP F

coverage is here! r Job Ti R ____ R d N Covered California open enrollment began October 1, 2013.

E Job#: 6029262_CA104497_fl Z I S E CS

Rancho Cordova, CA 95741-1150 Time: 4:36 PM 1-877-609-8711 sts

Assistance for the hearing and speech impaired i t Comment-enabled PDF Slug specs = Ticket

1-800-995-0852 Date: 09/24/13 Ar □ I have proofed □ □ ______ARTIST:

www.healthnet.com

9x12 w/a 1/4” capacity at spine and a 3/16” capacity pocket

dashed line is fpo for scores for folding—do not print Individual & Family Plan Covered California

Health Net PPO Insurance Plans Outline of Coverage and Exclusions and Limitations Plans available in Northern and Central California*

Proud to be Part of Covered California Table of Contents

Health Plans Read your Policy carefully ...... 1 PPO Platinum $20/$0 ...... 1 . . . PPO Gold $30/$0 ...... 3 . . . PPO Silver $45/$2,000 ...... 5 PPO Bronze $60/$5,000 ...... 7. . . PPO Catastrophic $0/$6,350 ...... 9. . . Major medical expense coverage ...... 11 . . Principal benefits and coverages ...... 11 . . Cost-sharing ...... 12 . . . Certification (prior authorization of services) ...... 12. . Exclusions and limitations ...... 12 Renewability of this Policy ...... 14. . . Premiums ...... 14 Claims to premium ratio ...... 14 Outline of Coverage

Health Net Life Insurance Company Individual & Family Health Insurance Plans major medical expense coverage

Read your Policy carefully This outline of coverage provides a brief description of the important features of your Health Net PPO Policy (Policy). This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth, in detail, the rights and obligations of both you and Health Net Life Insurance Company (Health Net Life). It is, therefore, important that you read your Policy carefully!

PPO Platinum $20/$0 – 9KZ Benefit description Insured person(s) responsibility Unlimited lifetime maximum In-network1,2,3 Out-of-network1,2,4 Plan maximums Calendar year deductible $0 single / $0 family $0 single / $0 family Out-of-pocket maximum5 $4,000 single / $8,000 single / $8,000 family $16,000 family Professional services Office visit $20 50% Specialist consultation $40 50% Preventive care services6 $0 Not covered X-ray and laboratory procedures $40 / $20 50% Rehabilitation and habilitation therapy $20 Not covered Hospital services Inpatient hospital facility services 10% 50% (includes maternity) Outpatient surgery (hospital or outpatient 10% 50% surgery center charges only) Skilled nursing facility 10% 50% Emergency services Emergency room (copayment waived if $150 $150 admitted) Urgent care $40 50% Ambulance services (ground and air) $150 $150

(continued)

1 Benefit description Insured person(s) responsibility Behavioral services Mental health / Chemical dependency 10% 50% rehabilitation (inpatient) Mental health / Chemical dependency $20 50% rehabilitation (outpatient) Home health care services (100 visits/year, in- and out-of-network 10% 50% combined) Other services Durable medical equipment 10% Not covered Acupuncture (medically necessary) $20 Not covered Chiropractic services Not covered Not covered Prescription drug coverage Brand-name calendar year deductible (per $0 Not covered insured) Prescription drugs (up to a 30-day supply)7 $5 / $15 / $25 Not covered Specialty drugs (most self-injectables) 10% Not covered Pediatric vision Eye exam 0% Not covered Glasses 1 pair per year Not covered

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage.

1 In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by Covered California and regardless of income, have no cost-sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost-sharing means copayments, including coinsurance and deductibles. 2 Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the Policy for details. 3 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 4 Please refer to the Policy for out-of-network reimbursement methodology. 5 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. 6 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 7 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

2 PPO Gold $30/$0 – 9KY Benefit description Insured person(s) responsibility Unlimited lifetime maximum In-network1,2,3 Out-of-network1,2,4 Plan maximums Calendar year deductible $0 single / $0 family $0 single / $0 family Out-of-pocket maximum5 $6,350 single / $12,700 single / $12,700 family $25,400 family Professional services Office visit $30 50% Specialist consultation $50 50% Preventive care services6 $0 Not covered X-ray and laboratory procedures $50 / $30 50% Rehabilitation and habilitation therapy $30 Not covered Hospital services Inpatient hospital facility services 20% 50% (includes maternity) Outpatient surgery (hospital or outpatient 20% 50% surgery center charges only) Skilled nursing facility 20% 50% Emergency services Emergency room (copayment waived if $250 $250 admitted) Urgent care $60 50% Ambulance services (ground and air) $250 $250 Behavioral services Mental health / Chemical dependency 20% 50% rehabilitation (inpatient) Mental health / Chemical dependency $30 50% rehabilitation (outpatient) Home health care services (100 visits/year, in- and out-of-network 20% 50% combined) Other services Durable medical equipment 20% Not covered Acupuncture (medically necessary) $30 Not covered Chiropractic services Not covered Not covered

(continued)

3 Benefit description Insured person(s) responsibility Prescription drug coverage Brand-name calendar year deductible $0 Not covered (per insured) Prescription drugs (up to a 30-day supply)7 $19 / $50 / $70 Not covered Specialty drugs (most self-injectables) 20% Not covered Pediatric vision Eye exam 0% Not covered Glasses 1 pair per year Not covered

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage. 1 In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by Covered California and regardless of income, have no cost-sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost- sharing means copayments, including coinsurance and deductibles. 2 Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the Policy for details. 3 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 4 Please refer to the Policy for out-of-network reimbursement methodology. 5 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. 6 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 7 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

4 PPO Silver $45/$2,000 – 9LB Benefits are subject to a deductible unless noted. Benefit description Insured person(s) responsibility Unlimited lifetime maximum In-network1,2,3 Out-of-network1,2,4 Plan maximums Calendar year deductible5 $2,000 single / $4,000 single / $4,000 family $8,000 family Out-of-pocket maximum $6,350 single / $12,700 single / (includes calendar year deductible)6 $12,700 family $25,400 family Professional services Office visit $45 (deductible waived) 50% Specialist consultation $65 (deductible waived) 50% Preventive care services7 $0 (deductible waived) Not covered X-ray and laboratory procedures $65 / $45 50% (deductible waived) Rehabilitation and habilitation therapy $45 (deductible waived) Not covered Hospital services Inpatient hospital facility services 20% 50% (includes maternity) Outpatient surgery (hospital or outpatient 20% (deductible waived) 50% surgery center charges only) Skilled nursing facility 20% 50% Emergency services Emergency room (copayment waived if $250 $250 admitted) Urgent care $90 (deductible waived) 50% Ambulance services (ground and air) $250 $250 Behavioral services Mental health / Chemical dependency 20% 50% rehabilitation (inpatient) Mental health / Chemical dependency $45 (deductible waived) 50% rehabilitation (outpatient) Home health care services (100 visits/year, in- and out-of-network 20% 50% combined) Other services Durable medical equipment 20% (deductible waived) Not covered

(continued) 5 Benefit description Insured person(s) responsibility Acupuncture (medically necessary) $45 (deductible waived) Not covered Chiropractic services Not covered Not covered Prescription drug coverage Brand-name calendar year deductible $250 Not covered (per insured) Prescription drugs (up to a 30-day supply)8 $19 / $50 / $70 Not covered Specialty drugs (most self-injectables) 20% Not covered Pediatric vision Eye exam 0% (deductible waived) Not covered Glasses 1 pair per year Not covered

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage. 1 In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by Covered California and regardless of income, have no cost-sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost- sharing means copayments, including coinsurance and deductibles. 2 Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the Policy for details. 3 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 4 Please refer to the Policy for out-of-network reimbursement methodology. 5 Any amount applied toward the calendar year deductible for covered services and supplies received from an in-network provider will not apply toward the calendar year deductible for out-of-network providers. In addition, any amount applied toward the calendar year deductible for covered services and supplies received from an out-of-network provider will not apply toward the calendar year deductible for in-network providers. 6 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. 7 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 8 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

6 PPO Bronze $60/$5,000 – 9KW Benefits are subject to a deductible unless noted. Benefit description Insured person(s) responsibility Unlimited lifetime maximum In-network1,2,3 Out-of-network1,2,4 Plan maximums Calendar year deductible5 $5,000 single / $10,000 single / $10,000 family $20,000 family Out-of-pocket maximum $6,350 single / $12,700 single / (includes calendar year deductible)6 $12,700 family $25,400 family Professional services Office visit Visits 1–3: $60 (ded waived) / 50% Visits 4+: $607 Specialist consultation $70 50% Preventive care services8 $0 (deductible waived) Not covered X-ray and laboratory procedures 30% 50% Rehabilitation and habilitation therapy 30% Not covered Hospital services Inpatient hospital facility services 30% 50% (includes maternity) Outpatient surgery (hospital or outpatient 30% 50% surgery center charges only) Skilled nursing facility 30% 50% Emergency services Emergency room (copayment waived if $300 $300 admitted) Urgent care Visits 1–3: $120 (ded waived) / 50% Visits 4+: $1207 Ambulance services (ground and air) $300 $300 Behavioral services Mental health / Chemical dependency 30% 50% rehabilitation (inpatient) Mental health / Chemical dependency Visits 1–3: $60 (ded waived) / 50% rehabilitation (outpatient) Visits 4+: $607 Home health care services (100 visits/year, in- and out-of-network 30% 50% combined)

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7 Benefit description Insured person(s) responsibility Other services Durable medical equipment 30% Not covered Acupuncture (medically necessary) $60 Not covered Chiropractic services Not covered Not covered Prescription drug coverage Subject to medical deductible Prescription drugs (up to a 30-day supply)9 $19 / $50 / $75 Not covered Specialty drugs (most self-injectables) 30% Not covered Pediatric vision Eye exam 0% (deductible waived) Not covered Glasses 1 pair per year Not covered

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage. 1 In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by Covered California and regardless of income, have no cost-sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost- sharing means copayments, including coinsurance and deductibles. 2 Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the Policy for details. 3 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 4 Please refer to the Policy for out-of-network reimbursement methodology. 5 Any amount applied toward the calendar year deductible for covered services and supplies received from an in-network provider will not apply toward the calendar year deductible for out-of-network providers. In addition, any amount applied toward the calendar year deductible for covered services and supplies received from an out-of-network provider will not apply toward the calendar year deductible for in-network providers. 6 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. 7 Visits 1–3 (combined between office visits, urgent care, prenatal and postnatal visits, outpatient mental health/substance abuse): The calendar year deductible is waived. Visits 4–unlimited: The calendar year deductible applies. 8 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 9 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

8 PPO Catastrophic $0/$6,350 – 9KX Benefits are subject to a deductible unless noted. Benefit description Insured person(s) responsibility Unlimited lifetime maximum In-network1,2 Out-of-network1,3 Plan maximums Calendar year deductible4 $6,350 single / $12,700 single / $12,700 family $25,400 family Out-of-pocket maximum $6,350 single / $12,700 single / (includes calendar year deductible)5 $12,700 family $25,400 family Professional services Office visit Visits 1–3: 0% (ded waived) / 50% Visits 4+: 0%6 Specialist consultation 0% 50% Preventive care services7 0% (deductible waived) Not covered X-ray and laboratory procedures 0% 50% Rehabilitation and habilitation therapy 0% Not covered Hospital services Inpatient hospital facility services 0% 50% (includes maternity) Outpatient surgery (hospital or outpatient 0% 50% surgery center charges only) Skilled nursing facility 0% 50% Emergency services Emergency room (copayment waived if 0% 0% admitted) Urgent care Visits 1–3: 0% (ded waived) / 50% Visits 4+: 0%6 Ambulance services (ground and air) 0% 0% Behavioral services Mental health / Chemical dependency 0% 50% rehabilitation (inpatient) Mental health / Chemical dependency Visits 1–3: 0% (ded waived) / 50% rehabilitation (outpatient) Visits 4+: 0%6 Home health care services (100 visits/year, in- and out-of-network 0% 50% combined)

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9 Benefit description Insured person(s) responsibility Other services Durable medical equipment 0% Not covered Acupuncture (medically necessary) 0% Not covered Chiropractic services Not covered Not covered Prescription drug coverage Subject to medical deductible Prescription drugs (up to a 30-day supply)8 0% Not covered Specialty drugs (most self-injectables) 0% Not covered Pediatric vision Eye exam 0% (deductible waived) Not covered Glasses 1 pair per year Not covered

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage. Catastrophic plans are available to individuals who are under age 30 . You may also be eligible for this plan if you are age 30 or older and are exempt from the federal requirement to maintain minimum essential coverage .

1 Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the Policy for details. 2 Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. 3 Please refer to the Policy for out-of-network reimbursement methodology. 4 Any amount applied toward the calendar year deductible for covered services and supplies received from an in-network provider will not apply toward the calendar year deductible for out-of-network providers. In addition, any amount applied toward the calendar year deductible for covered services and supplies received from an out-of-network provider will not apply toward the calendar year deductible for in-network providers. 5 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. 6 Visits 1–3 (combined between office visits, urgent care, prenatal and postnatal visits, outpatient mental health/substance abuse): The calendar year deductible is waived. Visits 4–unlimited: The calendar year deductible applies. 7 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 8 The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary. The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

10 Major medical expense • Home health care agency services coverage • Hospice care This category of coverage is designed to • Inpatient hospital services provide, to persons insured, benefits for • Medically necessary implanted lens that major hospital, medical and surgical expenses replaces the organic eye lens incurred as a result of a covered accident or • Medically necessary reconstructive surgery sickness. Benefits may be provided for daily hospital room and board, miscellaneous • Medically necessary surgically implanted hospital services, surgical services, anesthesia drugs services, in-hospital medical services, • Mental health care and chemical out-of-hospital care and prosthetic appliances dependency benefits subject to any deductibles, copayment • Outpatient hospital services provisions, or other limitations which may be • Outpatient infusion therapy set forth in the Policy. • Organ, tissue and bone marrow transplants Principal benefits and • Patient education (including diabetes coverages education) Please refer to the list below for a summary of • Pediatric vision as specified in the Policy each plan’s covered services and supplies. Also • Phenylketonuria (PKU) refer to the Policy you receive after you enroll • Pregnancy and maternity services in a plan. The Policy offers more detailed • Preventive care services information about the benefits and coverage included in your health insurance plan. • Professional services • Prostheses • Allergy serum • Radiation therapy, chemotherapy and renal • Allergy testing and treatment dialysis treatment • Ambulance services – ground ambulance • Rehabilitation therapy (including physical, transportation and air ambulance speech, occupational, cardiac, and transportation pulmonary therapy) • Ambulatory surgical center • Rental or purchase of durable medical • Bariatric (weight loss) surgery (not covered equipment out-of-network) • Self-injectable drugs • Care for conditions of pregnancy • Skilled nursing facility • Clinical trials • Sterilizations for males and females • Corrective footwear to prevent or treat • Treatment for dental injury, if medically diabetes-related complications necessary • Diabetic equipment • Diagnostic imaging (including X-ray) and laboratory procedures • Habilitation therapy

11 • Dental services, except as specified Reproductive health services in the Policy. Some hospitals and other providers do not provide one or more of the following • Treatment and services for services that may be covered under temporomandibular (jaw) joint disorders your Policy and that you or your family (TMJ) (except medically necessary surgical member might need: family planning; procedures). contraceptive services, including emergency contraception; sterilization, • Surgery and related services for the including tubal ligation at the time of purposes of correcting the malposition labor and delivery; infertility treatments; or improper development of the bones of or abortion. You should obtain more the upper or lower jaw, except when such information before you enroll. Call your procedures are medically necessary. prospective doctor, medical group, independent practice association, or • Food, dietary, or nutritional supplements, clinic, or call Health Net Life’s Customer except for formulas and special food Contact Center at 1-888-926-4988 to products to prevent complications of ensure that you can obtain the health phenylketonuria (PKU). care services that you need. • Vision care for adults age 19 and older, including certain eye surgeries to replace Cost-sharing glasses, except as specified in the Policy. Coverage is subject to deductible(s), • Optometric services or eye exercises coinsurances and copayments. Please consult for adults age 19 and older, except as the Policy for complete details. specifically stated elsewhere in the Policy. • Eyeglasses or contact lenses for adults age Certification (prior authorization 19 and older, except as specified in the of services) Policy. Some services are subject to precertification. • Sex changes. Please consult the complete list of services in • Services to reverse voluntary surgically the Policy. induced infertility. • Services or supplies that are intended to Exclusions and limitations impregnate a woman are not covered. The The following is a partial list of services that following services and supplies are excluded are not generally covered. For complete details from fertility preservation coverage: gamete about any plan’s exclusions and limitations, or embryo storage; use of frozen gametes please see the Policy for complete details. or embryos to achieve future conception; pre-implantation genetic diagnosis; donor • Services or supplies that are not medically eggs, sperm or embryos; gestational carriers necessary. (surrogates). • Any amounts in excess of the maximum • Certain genetic testing. amounts specified in the Policy. • Experimental or investigative services. • Cosmetic surgery, except as specified in • Routine physical exams, except for the Policy. preventive care services (e.g., physical exam for insurance, licensing, employment, 12 school, or camp). Any physical, vision or • Orthotics, unless custom made to fit the hearing exams, which are not related to a covered person’s body and as specified in diagnosis or treatment of illness or injury, the Policy. except as specifically stated in the Policy. • Educational services or nutritional • Immunizations or inoculations for adults or counseling, except as specified in the Policy. children for foreign travel or occupational • Hearing aids. purposes. • Obesity-related services except as stated in • Services not related to a covered illness or the Policy. injury. However, treatment of complications arising from non-covered services, such as • Any services received by Medicare benefits complications due to non-covered cosmetic without payment of additional premium. surgery, are covered. • Services received before your effective date • Custodial or domiciliary care. of coverage. • Inpatient room and board charges incurred • Services received after coverage ends. in connection with an admission to a • Services for which no charge is made to the hospital or other inpatient treatment covered person in the absence of insurance facility, primarily for diagnostic tests which coverage, except services received at a could have been performed safely on an charitable research hospital, which is not outpatient basis. operated by a governmental agency. • Inpatient room and board charges in • Physician self-treatment. connection with a hospital stay primarily • Services performed by a person who lives in for environmental change, physical therapy the covered person’s home or who is related or treatment of chronic pain. to the covered person by blood or marriage. • Any services or supplies furnished by a • Conditions caused by the covered person’s non-eligible institution, which is other than commission (or attempted commission) of a legally operated hospital or Medicare- a felony unless the condition was an injury approved skilled nursing facility, or which resulting from an act of domestic violence is primarily a place for the aged, a nursing or an injury resulting from a medical home or any similar institution, regardless condition. of how it is designated. • Conditions caused by release of nuclear • Expenses in excess of a hospital’s (or energy, when government funds are other inpatient facility’s) most common available. semiprivate room rate. • Any services provided by, or for which • Infertility services. payment is made by, a local, state or • Private duty nursing. federal government agency. This limitation • Over-the-counter medical supplies and does not apply to Medi-Cal, Medicaid or medications, except as specified in the Medicare. Policy. • Services for a surrogate pregnancy are • Personal comfort items. covered when the surrogate is a Health Net insured. However, when compensation is obtained for the surrogacy, the plan 13 shall have a lien on such compensation to Health Net Life does not require recover its medical expense. precertification for dialysis services or • Any outpatient drugs, medications or other maternity care. However, please call the substances dispensed or administered in Customer Contact Center at 1-888-926-4988 any outpatient setting except as stated in upon initiation of dialysis services or at the the Policy. time of the first prenatal visit. • Services and supplies obtained while in Precertification is also not required for a foreign country with the exception of behavioral health treatment for autism. emergency care. However, please provide Health Net Life with • Home birth, unless criteria for emergency documentation that a licensed physician or care have been met. licensed psychologist has established the diagnosis of autism. In addition, the qualified • Reimbursement for services for which the autism service provider must submit the covered person is not legally obligated initial treatment plan to Health Net Life. to pay the provider in the absence of Please refer to your Policy for details. insurance coverage. • Amounts charged by out-of-network Renewability of this Policy providers for covered medical services and Subject to the termination provisions treatment that Health Net Life determines discussed in the Policy, coverage will remain to be in excess of the covered expense. in effect for each month premiums are • Any expenses related to the following received and accepted by Health Net Life. items, whether authorized by a physician or not: (a) alteration of the covered person’s Premiums residence to accommodate the covered We may adjust or change your premium. If person’s physical or medical condition, we change your premium amount, notice will including the installation of elevators; (b) be mailed to you at least 60 days prior to the corrective appliances, except prosthetics, premium change effective date. Premiums are casts and splints; (c) air purifiers, air automatically adjusted for changes in your and your dependent spouse’s or registered conditioners and humidifiers; and (d) domestic partner’s ages. Premiums may educational services or nutritional be adjusted when your residence address counseling, except as specifically provided changes. in the Policy. • Disposable supplies for home use, except Claims to premium ratio for diabetic supplies as listed in the Policy. Health Net Life’s 2012 ratio of incurred Some services require precertification from claims to earned premiums for the Individual Health Net prior to receiving services. & Family PPO insurance plans was 92.5 Please refer to your Policy for details on percent. This ratio of incurred claims to what services and procedures require earned premiums calculation differs from precertification. the medical loss ratio calculation established under the Affordable Care Act.

14 *PPO plans are available in Contra Costa, Kern, Marin, Mariposa, Merced, Monterey, Napa, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, and Tulare counties. 6030372 CA110149 (1/14) Health Net IFP PPO insurance plans, Policy Form # P30601, are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. Covered California is a registered trademark of the State of California. All rights reserved.