Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021-12/31/2021 Health Net Life Insurance Co: Silver 70 PPO Coverage for: All Covered Members | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.healthnet.com/2021/eoc/ppo/silver70 or call 1-888-926-4988. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or www.myhealthnetca.com or you can call 1-888-926-4988 to request a copy. Important Questions Answers Why This Matters: $4,000 per person / $8,000 per family through the Generally, you must pay all of the costs from providers up to the deductible amount What is the overall preferred provider network. $8,000 per person / $16,000 before this plan begins to pay. If you have other family members on the plan, each deductible? family member must meet their own individual deductible until the total amount of per family for out-of-network providers per calendar year. deductible expenses paid by all family members meets the overall family deductible. Yes. Preventive care, physician office visits, x-ray & lab tests, imaging, outpatient surgery, emergency room care, This plan covers some items and services even if you haven’t yet met the deductible emergency medical transportation, urgent care, outpatient amount. But a copayment or coinsurance may apply. For example, this plan covers Are there services mental health & substance use disorder services, home covered before you health visits, outpatient rehabilitation & habilitation, certain preventive services without cost sharing and before you meet your deductible. meet your deductible? durable medical equipment, hospice, and pediatric dental See a list of covered preventive services at and vision care are covered before you meet your https://www.healthcare.gov/coverage/preventive-care-benefits/. deductible. Yes. Preferred pharmacy deductible $300 per person / Are there other $600 per family per calendar year. Pharmacy deductible You must pay all of the costs for these services up to the specific deductible amount deductibles for specific applies to tiers 1-4. There are no other specific before this plan begins to pay for these services. services? deductibles. What is the out-of- For preferred providers $8,200 per person / $16,400 per The out-of-pocket limit is the most you could pay in a year for covered services. If you pocket limit for this family. For out-of-network providers $25,000 per person / have other family members in this plan, they have to meet their own out-of-pocket plan? $50,000 per family per calendar year. limits until the overall family out-of-pocket limit has been met. Premiums, balance billing charges, drug discount, coupon What is not included in or copay cards for prescription drugs, penalties for non- Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out-of-pocket limit? certification and healthcare this plan doesn’t cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might Yes. For a list of , see Will you pay less if you preferred providers receive a bill from a provider for the difference between the provider’s charge and www.myhealthnetca.com/findadoctor or call 1-888-926­ use a network what your plan pays (balance billing). Be aware, your network provider might use an 4988. provider? out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? Page 1 of 7 SBC_SVR_70_IFP_PPO_2021 508_H8O_NO_P0L_DH8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Limitations, Exceptions, & Other Important Services You May Need Event Preferred Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to treat $40 copay/visit 50% coinsurance None an injury or illness deductible does not apply $80 copay/visit Specialist visit 50% coinsurance None If you visit a health deductible does not apply care provider’s office You may have to pay for services that aren’t or clinic Preventive care/screening/ preventive. Ask your provider if the services No charge 50% coinsurance immunization needed are preventive. Then check what your plan will pay for. Lab-$40 copay/visit Diagnostic test (x-ray, blood deductible does not apply 50% coinsurance None work) X-ray-$85 copay/visit If you have a test deductible does not apply If certification is not obtained a $250 penalty will Imaging (CT/PET scans, $325 copay/procedure 50% coinsurance apply through the preferred provider network, a MRIs) deductible does not apply $500 penalty will apply out-of-network. Preferred generic drugs $16 copay/retail order Supply/order: up to 30 day (retail); 31-90 day Not covered (tier 1) $32 copay/mail order (mail), except where quantity limits apply. Non-preferred generic and Preauthorization is required for select drugs or you $60 copay/retail order If you need drugs to preferred brand drugs (tier Not covered will be subject to a penalty of 50% of the average $120 copay/mail order treat your illness or 2) wholesale price, except for emergency care. condition Non-preferred brand drugs $90 copay/retail order Preferred pharmacy deductible applies $300 per More information about Not covered (tier 3) $180 copay/mail order member / $600 per family. prescription drug Supply/order: 30 day supply from specialty Rx is available at coverage except where quantity limits apply. Preauthorization www.myhealthnetca.co 20% coinsurance up to is required for select drugs or you will be subject to m/druglist Specialty drugs (Tier 4) Not covered $250 per prescription a penalty of 50% of the average wholesale price, except for emergency care. Pharmacy deductible applies $300 per member / $600 per family. * For more information about limitations and exceptions, see the plan or policy document at www.myhealthnetca.com Page 2 of 7 SBC_SVR_70_IFP_PPO_2021 H8O_NO_P0L_DH8 What You Will Pay Common Medical Limitations, Exceptions, & Other Important Services You May Need Event Preferred Provider Out--of--Network Provider Information (You will pay the least) (You will pay the most) Some outpatient surgical procedures require Facility fee (e.g., 20% coinsurance certification or a $250 penalty will apply through the 50% coinsurance If you have outpatient ambulatory surgery center) deductible does not apply preferred provider network, a $500 penalty will surgery apply out-of-network. 20% coinsurance Some outpatient surgical procedures require Physician/surgeon fees 50% coinsurance deductible does not apply certification. Facility fee­ Facility fee­ $400 copay/visit $400 copay/visit Emergency room care deductible does not apply deductible does not apply Copayment waived if admitted into the hospital. Professional services- Professional services- If you need immediate No charge No charge medical attention Emergency medical $250 copay/transport $250 copay/transport None transportation deductible does not apply deductible does not apply $40 copay/visit Urgent care 50% coinsurance None deductible does not apply If certification is not obtained in a non-emergency a Facility fee (e.g., hospital $250 penalty will apply through the preferred 20% coinsurance 50% coinsurance room) provider network, a $500 penalty will apply out-of­ If you have a hospital network. stay Certification is required for a hospital stay and 20% coinsurance Physician/surgeon fees 50% coinsurance some services received while admitted to the deductible may apply hospital. Office visit-$40 copay/visit Certification is not required for outpatient services deductible does not apply for mental health and substance use disorder Other than office visit­ diagnoses except for reconstructive surgery. If Outpatient services 50% coinsurance If you need mental 20% coinsurance up to $40 certification is required but not obtained a $250 health, behavioral copay/visit penalty will apply through the preferred provider health, or substance deductible does not apply network, a $500 penalty will apply out-of-network. abuse services Facility-20% coinsurance If certification is not obtained in a non-emergency a Physician­ $250 penalty will apply through the preferred Inpatient services 50% coinsurance 20% coinsurance provider network, a $500 penalty will apply out-of­ deductible may apply network. * For more information about limitations and exceptions, see the plan or policy document at www.myhealthnetca.com Page 3 of 7 SBC_SVR_70_IFP_PPO_2021 H8O_NO_P0L_DH8 What You Will Pay Common Medical Limitations, Exceptions, & Other Important Services You May Need Event Preferred Provider Out--of-Network- Provider Information (You will pay the least) (You will pay the most) Cost sharing does not apply for preventive services. Depending on the type of services, a Office visits No charge 50% coinsurance coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC If you are pregnant (i.e., ultrasound). Childbirth/delivery 20% coinsurance 50% coinsurance Coverage includes abortion services. professional services deductible may apply Childbirth/delivery facility 20% coinsurance 50% coinsurance Coverage includes abortion services.