|
BENEFITS |
| Preventive Care |
| Routine Physical Exams – Adults age 19 and over
Well child care to age 18
Immunizations
Gynecological (One pap test and one pelvic exam per calendar
year)
Mammograms |
$10 co-pay
No co-pay
No co-pay
$10 co-pay
No co-pay |
| Prescription
Drugs |
| All prescriptions, including Diabetic Medication and Supplies
Mail Order (up to a 90 day supply)
Contraceptives |
$10 co-pay
$20 co-pay
Covered |
| Outpatient
Care |
| Physician Office Visits
X-rays & Laboratory Tests
Physical and Occupational Therapy, up to 30 visits per
year
Cardiac Rehabilitation (Up to 12 weeks following surgery)
Chiropractic Care
Speech Therapy, up to 90 consecutive days
Diagnostic
Procedures and/or Surgery Performed in a Hospital or
Outpatient Surgical Care
Allergy Care |
$10 co-pay
No co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
No co-pay
$10 co-pay |
| Inpatient Care |
| Hospitalization – Semi-Private Room and Board
Physicians’, Surgeons’ and Nursing Services and Medications
Restorative Physical & Occupational Therapy, up to
90 consecutive days
Skilled Nursing Facility, 90 consecutive days |
No co-pay
No co-pay
No co-pay
No co-pay |
| Maternity Care |
| Pre-Natal & Post-Natal (From effective date of Health
Net coverage)
Hospital
Services for Mother & Child (including all newborn costs
even if mother is discharged
and newborn requires continued hospitalization)
Family Planning (Excludes In-Vitro Fertilization, GIFT, and
ZIFT) |
No co-pay
No co-pay
$10 co-pay |
| Vision Care |
| Routine
Exams (Annually for Children through age 18 and once every 2 calendar
years for Adults age 19 and over) |
$10 co-pay |
| Mental Health |
Outpatient
Visits, 20 visits per year (Medically necessary visits beyond
visit #6 must be approved in advance by Health Net)
Inpatient,
30 days per year (exchangeable with 60 partial Hospitalization
Sessions per year) |
$20 co-pay per visit
No co-pay |
| Alcohol/Substance Abuse |
| Inpatient Detoxification
Outpatient Rehabilitation, 60 visits per year
Inpatient Rehabilitation, 30 days per year |
No co-pay
$10 co-pay
No co-pay |
| Home Health or Hospice Care |
| Home HealthCare Visits and Service
Hospice Care |
No co-pay
Covered in full |
| Emergency Care |
| Emergency Room at Hospital
Urgent Care Facility |
$50 co-pay
$25 co-pay |
| Other Benefits |
| Durable Medical Equipment |
50% of the cost covered to a combined maximum of $1,500/year |
| Acupuncture, 20 visits per year |
$20 co-pay |
| Gym Membeship |
Discount |
| Massage |
Discount |