PPO* 250, 500 & 1000 Summary of Benefits - Cal Choice 250, 500 & 1000 summary of benefits 7 this matrix is intended to be used to help you compare coverage benefits and is a summary

PPO* 250, 500 & 1000 Summary of Benefits

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THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE SHOULDBE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Physician Services — OutpatientPCP or OB Office Visit –Specialist Office Visit –

Laboratory, X-Ray & Diagnostic

Physician Services — InpatientInpatient visits and consultations –Surgeons, assistants, anesthesiologists, pathologists, radiologists

Preventive Benefits Annual Physical Exam

Immunizations, Eye/Ear Screening(newborns up to age 17)

Adult Preventive Care (age 17 & older)

Hospital Services — OutpatientOutpatient surgery

Hospital Services — InpatientRoom, Board, Service and Supplies(Skilled Nursing Facility in Hospital)

Benefits PPO 250 PPO 500 PPO 1000In Network Out of Network1 In Network Out of Network1 In Network Out of Network1

$15 Copay

90% 2,3

90%

$25 Copay 4

$15 Copay

10%

$250 Copay-90% 3

$250 Copay-90% 3

70%

70% 2,3

70%

Not Covered

Not Covered

Not Covered

$250 Copay-70% 3,5

$250 Copay-70% 3,5

$30 Copay

80% 2,3

80%

Not Covered

$30 Copay

20%

$250 Copay-80% 3

$250 Copay-80% 3

60%

60% 2,3

60%

Not Covered

Not Covered

Not Covered

$250 Copay-60% 3,5

$250 Copay-60% 3,5

$30 Copay

80% 2,3

80%

Not Covered

$30 Copay

20%

$250 Copay-80% 3

$250 Copay-80% 3

60%

60% 2,3

60%

Not Covered

Not Covered

Not Covered

$250 Copay-60% 3,5

$250 Copay-60% 3,5

Deductible, Co-payment and Out-of-Pocket Maximum PPO 250 PPO 500 PPO 1000

Deductibles (Deductibles do not apply to the calendar year out-of-pocket maximum)• Individual $250 $500 $1,000• Family

Co-paymentsPhysician Office Visit Co-payment $15 $30 $30• Per visit

Calendar Year Out-of-Pocket MaximumIn-Network Providers• Individual $3,000 $4,000 $4,000• Family Per Individual Per Individual Per IndividualOut-of-Network Providers• Individual $5,000 $6,000 $6,000• Family Per Individual Per Individual Per Individual

Lifetime Maximum $5,000,000 $5,000,000 $5,000,000

PPO 250, 500 & 1000 Footnote GuideNote: All PPO plans exclude coverage for pre-existing conditions (except for pregnancy) for the first six months of coverage unless replacing prior creditable coverage (see Certificate for completeexplanation).

1 Out-of-network (OON) services: Scheduled coinsurance is a portion of the covered expense based on Customary & Reasonable charges. Member is responsible for any charges in excess of thecovered expense.

2 Prior certification only required for MRI, MUGA, PET, and SPECT.

3 These services require prior certification before being provided or received. If prior certification is not obtained, benefits are reduced to 50%. In addition, for uncertified outpatient services, a $50deductible is required for each visit; for uncertified inpatient admissions, a $250 deductible is required for each inpatient admission.

*Underwritten by Health Net Life Insurance Company.

Three family members must satisfy their individual deductibles to satisfy the family deductible

Max 100 days Max 60 days Max 60 days

Prescription Costs Participating Pharmacy Non-Participating Pharmacy† Mail Service PrescriptionsPPO 250/500* PPO 1000** PPO 250/500* PPO 1000** PPO 250/500* PPO 1000**

Outpatient Prescription Drugs(Not subject to deductible, includes oral contraceptives) Prescription costs

Generic Drugs $10 $10 $10 $10 $20 $20Formulary Brand Drugs $20 $25 $20 $25 $40 $50Non-Formulary Brand Drugs $35 $35 $35 $35 $70 $70Infertility Drug Max $2,000 $2,000

90%

90% 6

90% 6

$50 Copay-90%

90% 7

$15 Copay$250 Copay-90% 3

90% 8

90% 8

90% 3,9

90% 3

$15 Copay 10

Not Covered

70%

90% 6

90% 6

$50 Copay-70%

70% 7

70%$250 Copay-70% 3,5

70% 8

70% 8

70% 3,9

70% 3

70% 10

Not Covered

80%

80% 6

80% 6

$50 Copay-80%

80% 7

$30 Copay$250 Copay-80% 3

80% 8

Not Covered$250 Copay-80% 3,9

80% 3

Not Covered

Not Covered

60%

80% 6

80% 6

$50 Copay-60%

60% 7

60%$250 Copay-60% 3,5

60% 8

Not Covered$250 Copay-60% 3,9

60% 3

Not Covered

Not Covered

80%

80% 6

80% 6

$50 Copay-80%

80% 7

$30 Copay$250 Copay-80% 3

80% 8

Not Covered$250 Copay-80% 3,9

80% 3

Not Covered

Not Covered

60%

80% 6

80% 6

$50 Copay-60%

60% 7

60%$250 Copay-60% 3,5

60% 8

Not Covered$250 Copay-60% 3,9

60% 3

Not Covered

Not Covered

PPO 250, 500 & 1000 Summary of Benefits—con’t

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Pregnancy & Maternity CarePrenatal and postnatal care All necessary inpatient hospital services

Emergency Services ER Facility Resulting In Immediate Admission ER Facility Not Resulting In Admission ER Physician Services (Not Resulting In Admission)

Ambulance

Durable Medical Equipment(Max benefit is combined between in-network and out-of-network)

Mental Health Services for Severe Conditions(AB 88 Requirement on Page 6)

Outpatient Inpatient

Mental Health Services for Non-Severe ConditionsIncludes Alcohol/Substance Abuse Care Outpatient Mental Health ServicesOutpatient Chemical Dependency Inpatient medical acute detoxification only

Hospice - Routine Home Care

Chiropractic - Max. 12 Visits (Deductible Applies)

Acupuncture

Benefits PPO 250 PPO 500 PPO 1000In Network Out of Network1 In Network Out of Network1 In Network Out of Network1

* A separate $100 per member per calendar year deductible applies to formulary and non-formulary brand drugs. **A separate $150 per member per calendar year deductible applies to formulary and non-formulary brand drugs.†Prescriptions from non-participating pharmacies are covered. The member is responsible for the applicable copayment plus 50% of the pharmacy expense. Reimbursement is at Health Net’s contractedrate, not what the member paid.

Covered Under In-patient Hospital

Covered Under In-patient Hospital

Max $2000 Max $1000 Max $1000

Lifetime Max $5000 Lifetime Max $5000 Lifetime Max $5000

PPO 250, 500 & 1000 Footnote Guide- continued

4 Limited to one exam each calendar year and a maximum payment of $200 for the exam and all related services (age 17 and older only).

5 OON hospital services mixed fee schedule: Maximum allowable each day for inpatient hospital is 50% of billed charges.

6 An additional $100 emergency room or urgent care deductible is required if the member is not admitted as an inpatient. The deductible is waived if admitted.

7 Prior certification required only when an individual item amount is greater than $500.

8 Non-Severe mental health outpatient consultations and chemical dependency outpatient consultations are limited to a combined maximum for PPO & OON of 20 visits per calendar year. Themaximum amount payable for each visit is $25. For the PPO 250 plan, the 20 visits are limited to a shared maximum between outpatient mental health services and outpatient chemicaldependency rehabilitation.

9 Limited to a 3 day maximum per member each calendar year. For the PPO 250 plan, limited to a $175 maximum allowable each day.

10 After the initial visit, subsequent visits require an approved chiropractic treatment plan. The maximum amount payable for each OON visit is $25 with a maximum of 12 visits per year combinedbetween PPO and OON.

PPO Exclusions and Limitations

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CalChoice PPO 250, 500 AND 1000Summary of Benefit Exclusions and Limitations

Unless specifically covered in the group’s health service contract or as an optional benefit, no benefitsare provided for:

• Artificial insemination;

• Charges in excess of rate negotiated between any organizationand the physician, hospital or other provider;

• Conception by medical procedures (IVF, GIFT and ZIFT);

• Conditions resulting from the release of nuclear energy whengovernment funds are available;

• Corrective or support appliances or supplies;

• Cosmetic services or supplies;

• Custodial or live-in care;

• Dental services;

• Disposable supplies for home use;

• Experimental or investigational procedures, except as set outunder the “Clinical trials” and “If you have a disagreement withour plan” sections of this SB/DF;

• Genetic testing is not covered except when determined byHealth Net Life to be medically necessary. The prescribingphysician must request prior authorization for coverage;

• Hypnosis;

• Non-eligible institutions. This plan only covers services orsupplies provided by a legally operated hospital, Medicare-approved skilled nursing facility or other properly licensedfacility as specified in the Certificate. Any institution that isprimarily a place for the aged, a nursing home or similarinstitution, regardless of how it is designated, is not an eligibleinstitution. Services or supplies provided by such institutions arenot covered;

• Orthoptics (eye exercises);

• Orthotic items for the foot, except when incorporated into acast, splint, brace or strapping of the foot or when medicallynecessary for the treatment of diabetes;

• Personal or comfort items;

• Physician self-treatment;

• Physician treating immediate family members;

• Pre-existing conditions that occur during the first six months ofyour coverage, except as stated elsewhere;

• Private rooms when hospitalized, unless medically necessary;

• Private-duty nursing;

• Refractive eye surgery unless medically necessary,recommended by your treating physician and authorized byHealth Net Life;

• Reversal of surgical sterilization;

• Routine physical examinations for insurance, licensing,employment, school, camp or other nonpreventive purposes;

• Outpatient prescriptions drugs or medications (except as notedunder “Prescription drug program”);

• Services and supplies determined not to be medically necessaryas defined in the Certificate;

• Services and supplies not specifically listed in the Certificate ascovered expenses;

• Services and supplies that do not require payment in theabsence of insurance;

• Services for an injury incurred in the commission (or attemptedcommission) of a crime;

• Services for a surrogate pregnancy are covered. However, whencompensation is obtained for the surrogacy, the Plan shall havea lien on such compensation to recover its medical expense;

• Services not related to a covered illness or injury, except asprovided under preventive care and annual routine exams;

• Services received before effective date or after termination ofcoverage, except as specifically stated in the “Extension ofBenefits” section of the Certificate;

• Sex change services;

• Treatment of jaw joint disorders or surgical procedures to reduceor realign the jaw, unless medically necessary;

• Treatment of obesity, weight reduction or weight management,except for treatment of morbid obesity.

The above is a partial list of the principal exclusions andlimitations applicable to the medical portion of your Health Net Life Insurance Company PPO plan. The Certificate, which you will receive if you enroll in this plan, will contain the full list.