This HealthNet plan is available to Active and Category 2 Employees and Dependents and Non-Medicare Eligible and Medicare Eligible Retirees.
| ANNUAL COPAYMENT LIMIT | |
|---|---|
| For each member | $1,500 |
| For two-party | $3,000 |
| For each family (3 or more members) | $4,500 |
| OUTPATIENT CARE | |
| Administration of anesthetics | No charge |
| Allergy injection services (serum not included) | $15 copayment |
| Allergy serum | Not covered |
| Allergy testing | No charge |
| All other injections | $15 copayment |
| Annual routine physical examinations | Not covered |
| Chemotherapy (professional services only) | No charge |
| Circumcision of Newborn | No charge |
| Complications of pregnancy including medically necessary abortions | No charge |
| Dental services (when medically necessary to properly monitor, control, or treat a severe medical condition when excluded dental services are being performed | No charge |
| Elective abortions | $150 copayment |
| Genetic testing of fetus | No charge |
| Immunizations for foreign travel/occupational purposes | 20% copayment |
| Normal delivery, Cesarean section (includes newborn inpatient care provided by a member physician) | No charge |
| Nuclear medicine (professional services only) | No charge |
| Other immunizations (except foreign travel/occupational - see above) | No charge |
| Periodic health evaluations (includes routine, preventative care, and well-baby care) | $15 copayment |
| Physician visit to hospital or skilled nursing facility (excluding care for mental disorders) | No charge |
| Physician visit to member's home (at discretion of physician) | $20 copayment |
| Postnatal Office Visit | No charge |
| Prenatal Office Visit | $15 copayment |
| Rehabilitation therapy (inpatient/outpatient physical, speech, occupational and respiratory therapy; provided as long as significant improvement is expected) | $15 copayment |
| Renal dialysis (professional services only) | No charge |
| Specialist consultations (includes OB/GYN self-referral) | $15 copayment |
| Surgeon/Assistant Surgeon in hospital or PPG | No charge |
| Vision and hearing examinations | $15 copayment |
| Visit to a physician, physician assistant or nurse practitioner at a Preferred Provider Group (PPG) | $15 copayment |
| X-ray and laboratory procedures | No charge |
| HOSPITAL INPATIENT CARE | |
| Unlimited days of hospital care in a semi-private room or ICU with ancillary services (excluding care for mental disorders) | $250 |
| Maternity care (includes routine nursery charges) | $250 |
| Organ and bone marrow transplants (non-experimental and noninvestigative Professional services only) | No charge |
| Outpatient Services | No charge |
| Skilled Nursing Facility (limited to 100 days per calendar year) | $250 |
| FAMILY PLANNING | |
| Contraceptive devices | Not covered |
| Infertility services(including professional services, inpatient and outpatient care, treatment by injection and prescription drugs, if applicable) | 50% copayment |
| Reversal of sterilization | Not covered |
| Sterilization of females | $150 copayment |
| Sterilization of males | $50 copayment |
| MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES | |
| Administered by Managed Health network (MHN). Refer to the MHN telephone number on the back of your HealthNet ID card. | |
| OTHER SERVICES | |
| Air ambulance | No charge |
| Blood, blood plasma, blood factors and blood derivatives | No charge |
| Durable medical equipment | No charge |
| Diabetic supplies | No charge |
| Ground Ambulance | No charge |
| Hearing Aids | Not covered |
| Home health visit (the copayment starts the 31st calendar day after the first visit) | $15 copayment |
| Hospice Care | No charge |
| Medical social services | No charge |
| Patient education | No charge |
| Prosthesis (replacing body parts) | No charge |
| EMERGENCY CARE/URGENTLY NEEDED CARE | |
| Use of emergency room (facility and professional services) | $100 copayment |
| Use of urgent care center (facility and professioanl services) | $50 copayment |
| -Copayment is waived if patient is admitted to the hospital. | |
This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.
Actives and Early Retirees - download your specific HealthNet Evidence of Coverage
Medicare-Eligible Retirees - download your HealthNet Evidence of Coverage or your Prescription Plan Coverage
Download your HealthNet Enrollment form
HealthNet Medicare Part D Enrollment Form