Summary of Benefits

and Disclosure Form

University of California
Blue & Gold HMO (Plan DW7)

Effective 1/1/2017
DELIVERING CHOICES
When it comes to your health care, the best decisions are made with the best choices. Health Net of
California, Inc. (Health Net) provides you with ways to help you receive the care you deserve. This
Summary of Benefits and Disclosure Form (SB/DF) answers basic questions about this versatile plan.

If you have further questions, contact us:

By phone at 1-800-539-4072,

Or write to: Health Net of California

P.O. Box 10348
Van Nuys, CA 91410-0348

Please examine your options carefully before declining this coverage..

This Summary of benefits/disclosure form (SB/DF) is only a summary of your health plan. The
plans Evidence of Coverage (EOC), which will be issued electronically on Health Net's website at
www.healthnet.com/uc, contains the exact terms and conditions of your Health Net coverage. It is
important for you to carefully read this SB/DF and the plans EOC thoroughly once received,
especially those sections that apply to those with special health care needs. This SB/DF includes a
matrix of benefits in the section titled "Schedule of benefits and coverage."

(1/1/2017) SBID: 86065 86065

PLEASE READ THIS IMPORTANT NOTICE ABOUT THE HEALTH NET
BLUE & GOLD HMO NETWORK HEALTH PLAN SERVICE AREA AND
OBTAINING SERVICES FROM HEALTH NET BLUE & GOLD HMO
NETWORK PHYSICIAN AND HOSPITAL PROVIDERS
Except for emergency care, benefits for Physician and Hospital services under this Health Net HMO
Network ("Health Net Blue & Gold HMO Network") plan are only available when you live or work in
the Health Net Blue & Gold Network service area and use a Health Net Blue & Gold HMO Network
Physician or Hospital. When you enroll in this Health Net Blue & Gold HMO Network plan, you may
only use a Physician or Hospital who is in the Health Net Blue & Gold HMO Network and you must
choose a Health Net Blue & Gold HMO Network Primary Care Physician (PCP). You may obtain
ancillary or pharmacy covered services and supplies from any Health Net participating ancillary or
pharmacy provider.

A few Enrollees who live or work in some remote or rural zip codes of the Health Net Blue & Gold
Network service area, may need to travel up to or exceeding thirty miles for access to a Health Net Blue
& Gold Network provider. You can confirm if the zip code where you live or work is affected by calling
the telephone number on your Health Net identification card, or by logging on to www.healthnet.com/uc.

OBTAINING COVERED SERVICES UNDER THE HEALTH NET BLUE & GOLD HMO
NETWORK PLAN

TYPE OF PROVIDER HOSPITAL PHYSICIAN ANCILLARY PHARMACY

AVAILABLE FROM *Only Blue *Only Blue & Gold All Health Net All Health Net
& Gold Network Physicians contracting participating
Network ancillary pharmacies
Hospitals providers

* The benefits of this plan for Physician and Hospital services are only available for covered
services received from a Health Net Blue & Gold HMO Network Physician or Hospital, except
for (1) urgently needed care outside a 30-mile radius of your Physician Group and all
emergency care; (2) referrals to non-Health Net Blue & Gold HMO Network providers are
covered when the referral is issued by your Health Net Blue & Gold HMO Network Physician
Group; and (3) covered services provided by a non-Health Net Blue & Gold HMO Network
provider when authorized by Health Net. Please refer to "Specialists and referral care" in the
"How the plan works" section and "Emergencies" in the "Benefits and coverage" section for
more information.

The coinsurance percentage you pay is based on the negotiated rate with the treating provider. Health Net
Blue & Gold HMO Network providers may or may not have lower rates than Health Nets full network
providers, to whom you may be referred by your PCP or your Physician Group for these specific services

The service area and a list of Health Net Blue & Gold HMO Network Physician and Hospital providers
are listed online at our website: www.healthnet.com/uc. A copy of the Health Net Blue & Gold HMO
Network Provider listing may be ordered online or by calling Health Net Member Services at the phone
number on the back cover.

Not all physicians and hospitals who contract with Health Net are Blue & Gold HMO Network
providers. Only those physicians and hospitals specifically identified as participating in the Blue &
Gold HMO Network may provide services under this plan, except as described in the chart above.
Unless specifically stated otherwise, use of the following terms in this Summary of benefits/disclosure
form (SB/DF) solely refer to Blue & Gold HMO Network as explained above.

Health Net
Health Net service area
Hospital
Member physician, participating physician group, primary care physician, physician, participating
provider, contracting physician groups and contracting providers
Network

If you have any questions about the Blue & Gold HMO Network Service Area, choosing your Blue &
Gold HMO Network Primary Care Physician, how to access specialist care or your benefits, please call
Health Net's Customer Contact Center at the phone number on the back cover.
 TABLE OF CONTENTS

HOW THE PLAN WORKS .............................................................................................. 3

SCHEDULE OF BENEFITS AND COVERAGE .............................................................. 5

LIMITS OF COVERAGE ............................................................................................... 12

BENEFITS AND COVERAGE ...................................................................................... 14

UTILIZATION MANAGEMENT ..................................................................................... 17

PAYMENT OF FEES AND CHARGES ......................................................................... 18

FACILITIES ................................................................................................................... 20

RENEWING, CONTINUING OR ENDING COVERAGE ............................................... 22

IF YOU HAVE A DISAGREEMENT WITH OUR PLAN ................................................ 24

ADDITIONAL PLAN BENEFIT INFORMATION ........................................................... 25

BEHAVIORAL HEALTH SERVICES ............................................................................ 25

PRESCRIPTION DRUG PROGRAM ............................................................................ 25

CHIROPRACTIC CARE PROGRAM ............................................................................ 30

ACUPUNCTURE CARE PROGRAM ............................................................................ 31

How the plan works
Please read the following information so you will know from whom health care may be obtained, or what
physician group to use.

SELECTION OF PHYSICIANS AND PHYSICIAN GROUPS

When you enroll with Health Net, you choose a contracting physician group. From your physician group, you
select one doctor to provide basic health care; this is your Primary Care Physician (PCP).

Health Net requires the designation of a Primary Care Physician. A Primary Care Physician provides and
coordinates your medical care. You have the right to designate any Primary Care Physician who participates
in our network and who is available to accept you or your family members, subject to the requirements of the
physician group. For children, a pediatrician may be designated as the Primary Care Physician. Until you
make this designation, Health Net designates one for you. For information on how to select a Primary Care
Physician and for a list of the participating Primary Care Physicians, refer to your Health Net Group HMO
Directory (Health Net HMO Directory). The Health Net HMO Directory is also available on the Health Net
website at www.healthnet.com/uc.

Whenever you or a covered family member needs health care, your PCP will provide the medically necessary
care. Specialist care is also available, when referred by your PCP or physician group.

You do not have to choose the same physician group or PCP for all members of your family. physician
groups, with names of physicians, are listed in the Health Net HMO Directory.

HOW TO CHOOSE A PHYSICIAN

Choosing a PCP is important to the quality of care you receive. To be comfortable with your choice, we suggest
the following:

Discuss any important health issues with your chosen PCP;

Ask your PCP or the physician group about the specialist referral policies and hospitals used by the physician
group; and
Be sure that you and your family members have adequate access to medical care, by choosing a doctor located
within 30 miles of your home or work.

SPECIALISTS AND REFERRAL CARE

If you need medical care that your PCP cannot provide, your PCP may refer you to a specialist or other health
care provider for that care.

You do not need prior authorization from Health Net or from any other person (including a Primary Care
Physician) in order to obtain access to obstetrical or gynecological care from a health care professional in our
network who specializes in obstetrics or gynecology. The health care professional, however, may be required to
comply with certain procedures, including obtaining prior authorization for certain services, following a pre-
approved treatment plan, or procedures for making referrals. For a list of participating health care professionals
who specialize in obstetrics or gynecology, refer to your Health Net Group HMO Directory (Health Net HMO
Directory). The Health Net HMO Directory is also available on the Health Net website at www.healthnet.com/uc.
HMO SPECIALIST ACCESS

Health Net offers Rapid Access, a service that makes it easy for you to quickly connect with a specialist in
Health Nets network. Ask your group or check the Health Net HMO Directory to see if your physician group
allows "self-referrals" or "direct referrals" to specialists within the same group. Self-referral allows you to contact
a specialist directly for consultation and evaluation. Direct referral allows your doctor to refer you directly to a
specialist without the need for physician group authorization. Information about your physician groups referral
policies is also available to you on our web site at www.healthnet.com/uc.

HOW TO ENROLL

Complete the enrollment form found in the enrollment packet and return the form to your employer. If a form is
not included, your employer may require you to use an electronic enrollment form or an interactive voice response
enrollment system. Please contact your employer for more information.

Some hospitals and other providers do not provide one or more of the following services that may be
covered under the plan's Evidence Of Coverage and that you or your family member might need:

Family planning
Contraceptive services; including emergency contraception
Sterilization, including tubal ligation at the time of labor and delivery
Infertility treatments
Abortion

You should obtain more information before you enroll. Call your prospective doctor, medical group,
independent practice association or clinic, or call the Health Net Customer Contact Center at 1-800-
539-4072 to ensure that you can obtain the health care services that you need.
Schedule of benefits and coverage
This MATRIX is intended to be used to help you compare coverage benefits and is a summary only. The PLAN
CONTRACT AND Evidence of Coverage (EOC) should be consulted for a detailed description of coverage
benefits and limitations.

The copayment amounts listed below are the fees charged to you for covered services you receive. Copayments
can be either a fixed dollar amount or a percentage of Health Net's cost for the service or supply and is agreed to
in advance by Health Net and the contracted provider. Fixed dollar copayments are due and payable at the time
services are rendered. Percentage copayments are usually billed after the service is received.

Principal benefits and coverage matrix

Deductibles ............................................................................................... None
Lifetime maximums .................................................................................. None
Out-of-Pocket maximum
One member ............................................................................................ $1000
Two members .......................................................................................... $2000
Family (three members or more) ............................................................. $3000

Once your payments for covered services and supplies equals the amount shown above in any one calendar year,
including covered services and supplies provided by Optum and American Specialty Health Plans of California, Inc.
(ASH Plans), no additional copayments for covered services and supplies are required for the remainder of the
calendar year. Once an individual member in a family meets the individual out-of-pocket maximum, the other enrolled
family members must continue to pay copayments for covered services and supplies until the total amount of
copayments paid by the family reaches the family out-of-pocket maximum or each enrolled family member individually
meets the individual out-of-pocket maximum.
Payments for services not covered by this plan will not count toward this calendar year out-of-pocket maximum,
unless otherwise noted. You must continue to pay copayments for any services and supplies that do not apply to the
out-of-pocket maximum.

Professional services

The copayments below apply to professional services only. Services that are rendered in a hospital or an outpatient
center are also subject to the hospital or outpatient center services copayment. See "Hospitalization services" and
"Outpatient services" in this section to determine if any additional copayments may apply.
Visit to physician ..................................................................................... $20
Specialist or specialty care consultations ........................................... $20
Surgeon or assistant surgeon services in Hospital ................................ Covered in full
Surgeon or assistant surgeon services in the
physician groups office .................................................................... $20
Administration of anesthetics .................................................................. Covered in full
Physician visit to members home at your
physician's discretion and in accordance with
criteria set by Health Net ..................................................................... $20
Prenatal and postnatal office visits* ........................................................ Covered in full
Normal delivery, cesarean section, newborn
inpatient care ....................................................................................... Covered in full
Treatment of complications of pregnancy ............................................... See note below**
 Contraceptive devices (including but not limited to
intrauterine devices (IUD) and Depo Provera
injections) ............................................................................................ Covered in full
Laboratory procedures and diagnostic imaging
(including x-ray) services .................................................................... Covered in full
CT, SPECT, MRI, MUGA and PET ................................................... Covered in full
Rehabilitative therapy (includes physical, speech,
occupational, cardiac rehabilitation and
pulmonary rehabilitation therapy) ....................................................... $20
Organ and stem cell transplants (non-experimental
and non-investigational) ...................................................................... Covered in full
Chemotherapy ......................................................................................... Covered in full
Radiation therapy .................................................................................... Covered in full
Vision and hearing examinations (for diagnosis or
treatment, including refractive eye examinations) .............................. $20

Self-referrals are allowed for obstetrics and gynecological services including preventive care, pregnancy and
gynecological ailments. Copayment requirements may differ depending on the services provided.
Podiatrist services may be covered under Specialist consultation as authorized by your Physician Group.

Surgery includes surgical reconstruction of a breast incident to mastectomy (including lumpectomy), including
surgery to restore symmetry; also includes prosthesis and treatment of physical complications at all stages of
mastectomy, including lymphedema. While Health Net and your physician group will determine the most appropriate
services, the length of hospital stay will be determined solely by your PCP.

*Prenatal, postnatal and newborn care that are preventive care services are covered in full. See
copayment listings for preventive care services below. If other non-preventive care services are
received during the same office visit, the above copayment will apply for the non-preventive care
services.

**Applicable copayment requirements apply to any services and supplies required for the treatment of an illness or
condition, including but not limited to, complications of pregnancy. For example, if the complication requires an
office visit, then the office visit copayment will apply.

Please see section below for Chiropractic care and Acupuncture services covered through American Specialty
Helath Plans of Claifornia Inc. (ASH Plans).

Preventive care
Preventive care services .......................................................................... Covered in full

Preventive care services are covered for children and adults, as directed by your physician, based on the guidelines
from the U.S. Preventive Services Task Force Grade A&B recommendations, the Advisory Committee on
Immunization Practices that have been adopted by the Center for Disease Control and Prevention, the guidelines for
infants, children, adolescents and womens preventive health care as supported by the Health Resources and Services
Administration (HRSA).
Preventive care services include, but are not limited to, annual preventive physical examinations, periodic health
evaluations, immunizations, screening and diagnosis of prostate cancer, diagnostic preventive procedures including
preventive care services for pregnancy, and preventive vision and hearing screening examinations, a human
papillomavirus (HPV) screening test that is approved by the federal Food and Drug Administration (FDA), and the
option of any cervical cancer screening test approved by the FDA.
 One breast pump and the necessary supplies to operate it (as prescribed by your physician) will be covered for each
pregnancy at no cost to the member. We will determine the type of equipment, whether to rent or purchase the
equipment and the vendor who provides it. Breast pumps can be obtained by calling the Customer Contact Center at
the phone number listed on the back cover of this booklet.

Allergy treatment and other injections (except for infertility injections)

Allergy testing ......................................................................................... $20
Allergy serum .......................................................................................... Covered in full
Allergy injection services ........................................................................ $20
Immunizations -- To meet foreign travel
requirements ....................................................................................... Covered in full
Immunizations -- To meet occupational
requirements ....................................................................................... Covered in full
Injections (except for infertility)
Injectable drugs administered by a physician (per
dose).................................................................................................. $20
Self injectable drugs ........................................................................... $20

Self-injectable drugs (other than insulin) are considered specialty drugs, which require prior authorization and
must be obtained from a contracted specialty pharmacy vendor. Specialty drugs require prior authorization from
Health Net. Please refer to the plan's EOC for additional information.

Injections for the treatment of infertility are described below in the "Infertility services" section.
Outpatient facility services
Outpatient facility services (other than surgery) ..................................... Covered in full
Outpatient surgery (surgery performed in a hospital
or outpatient surgery center only)........................................................ $100

Outpatient care for infertility is described below in the "Infertility services" section.
Hospitalization services
Semi-private hospital room or special care unit with
ancillary services, including maternity care (per
admission; unlimited days) ................................................................. $250
Skilled nursing facility stay (limited to 100 days
per calendar year) ............................................................................... Covered in full
Physician visit to hospital or skilled nursing facility............................... Covered in full

The above inpatient hospitalization copayment is applicable for each admission of hospitalization for an adult,
pediatric or newborn patient. If a newborn patient requires admission to a special care unit, a separate copayment for
inpatient hospital services for the newborn patient will apply.

Inpatient care for infertility is described below in the "Infertility services" section.
Emergency health coverage
Emergency room (professional and facility charges) .............................. $75
Urgent care center (professional and facility
charges) ............................................................................................... $20

Copayments for emergency room or urgent care center visits will not apply if the member is admitted as an inpatient
directly from the emergency room or urgent care center.
Ambulance services
Ground ambulance .................................................................................. Covered in full
Air ambulance ......................................................................................... Covered in full
Prescription drug coverage

Please refer to the "Prescription drug program" section of this SB/DF for applicable definitions,
benefit descriptions and limitations. Copayments for prescription drugs do not apply to the out-of-
pocket maximum, except copayments for peak flow meter and inhaler spacers used for the treatment
of asthma, and diabetic supplies.
Retail participating pharmacy (up to a 30-day supply)
Level I drugs (primarily generic) ........................................................... $5
Level II drugs (primarily preferred brand name
drugs, peak flow meters, inhaler spacers and
diabetic supplies, including insulin) ................................................. $25
Level III drugs or non-preferred drugs not on the
Commercial Formulary .................................................................... $40
Appetite Suppressants ............................................................................. 50%
Lancets .................................................................................................... Covered in full
Preventive drugs (including smoking cessation
drugs) and womens contraceptives* .................................................. Covered in full
Mail-order program (up to a 90-day supply of maintenance drugs)
UC Walk up Service & CVS Caremark (up to a 90-day supply of maintenance medications) at UC
Medical Center Pharmacies & CVS Retail Pharmacies
Level I drugs (primarily generic) ........................................................... $10
Level II drugs (primarily preferred brand name
drugs, peak flow meters, inhaler spacers and
diabetic supplies, including insulin) ................................................. $50
Level III drugs or non-preferred drugs not on the
Commercial Formulary .................................................................... $80
Lancets .................................................................................................... Covered in full
Preventive drugs (including smoking cessation
drugs) and womens contraceptives* .................................................. Covered in full
For information about Health Nets Commercial Formulary, please call the Customer Contact Center at the
telephone number on the back cover.
Orally administered anti-cancer drugs will have a copayment maximum of $200 for an individual prescription of up
to a 30-day supply.

Generic drugs will be dispensed when a generic drug equivalent is available unless a brand name drug is
specifically requested by the physician or the member. When a brand name drug is dispensed and a generic
equivalent is commercially available, the member must pay the difference between the generic equivalent and the
brand name drug plus the Level I or Level III drug copayment.
However, if the brand name drug is medically necessary and the physician obtains prior authorization from Health
Net, then only the Level II or Level III drug copayment, as appropriate, will be applicable.
* Preventive drugs (including smoking cessation drugs) and womens contraceptives that are approved by the Food
and Drug Administration are covered at no cost to the member. Preventive drugs are prescribed over-the-counter
drugs or prescription drugs that are used for preventive health purposes per the U.S. Preventive Services Task
Force A and B recommendations.
 *If a brand name drug is dispensed, and there is a generic equivalent commercially available, you will be required to
pay the difference in cost between the generic and brand name drug. However, if a brand name drug is medically
necessary and the physician obtains prior authorization from Health Net, then the brand name drug will be
dispensed at no charge.

Percentage copayments will be based on Health Nets contracted pharmacy rate.

If the retail price is less than the applicable copayment, then you will pay the retail price prescription drug covered
expenses are the lesser of Health Nets contracted pharmacy rate or the pharmacys retail price for covered
prescription drugs.
This plan uses the Commercial Formulary. The Health Net Commercial Formulary is the approved list of medications
covered for illnesses and conditions. It is prepared by Health Net and distributed to Health Net contracted physicians
and participating pharmacies. The Commercial Formulary also shows which drugs are Level I, Level II or Level III,
so you know which copayment applies to the covered drug. Drugs that are not on the Commercial Formulary (that are
not excluded or limited from coverage) are also covered at the Level III drug copayment.
Some drugs require prior authorization from Health Net. Urgent requests from physicians for authorization are
processed as soon as possible, not to exceed 24 hours, after Health Nets receipt of the request and any additional
information requested by Health Net that is reasonably necessary to make the determination. Routine requests from
physicians are processed in a timely fashion, not to exceed 72 hours, as appropriate and medically necessary, for the
nature of the members condition after Health Nets receipt of the information reasonably necessary and requested by
Health Net to make the determination. For a copy of the Commercial Formulary, call the Customer Contact Center at
the number listed on the back cover of this booklet or visit our website at www.healthnet.com/uc.

Medical Supplies
Durable medical equipment (including nebulizers,
face masks and tubing for the treatment of
asthma) ............................................................................................... Covered in full
Orthotics (such as bracing, supports and casts) ....................................... Covered in full
Corrective footwear ................................................................................. Covered in full
Diabetic Equipment See the "Prescription drug
program" section of this SB/DF for diabetic
supplies benefit information. .............................................................. Covered in full
Diabetic footwear .................................................................................... Covered in full
Prostheses ................................................................................................ Covered in full

Breastfeeding devices and supplies, as supported by HRSA guidelines, are covered under
Preventive care in this section.

Diabetic equipment covered under the medical benefit (through "Diabetic equipment")
includes blood glucose monitors designed for the visually impaired, insulin pumps and related
supplies, and corrective footwear. Diabetic equipment and supplies covered under the
prescription drug benefit include insulin, specific brands of blood glucose monitors and testing
strips, Ketone urine testing strips, lancets and lancet puncture devices, specific brands of pen
delivery systems for the administration of insulin (including pen needles) and insulin syringes.
In addition, the following supplies are covered under the medical benefit as specified: visual aids (excluding
eyewear) to assist the visually impaired with the proper dosing of insulin are provided through the protheses
benefit; Glucagon is provided through the self-injectable benefit. Self-management training, education and
medical nutrition therapy will be covered only when provided by licensed health care professionals with expertise
in the management or treatment of diabetes (provided through the patient education benefit).
Home health services
Home health services ............................................................................. Covered in full

Other services
Medical social services ............................................................................ Covered in full
Patient education ..................................................................................... Covered in full
Sterilization of females performed in Contracting
Physician Groups office ..................................................................... Covered in full
Sterilization of females performed in Hospital ....................................... Covered in full
Sterilization of males performed in Contracting
Physician Groups office ..................................................................... $20
Sterilization of males performed in Hospital........................................... Covered in full
Hearing aids (2 standard aid(s) with a benefit
maximum of $2,000 every 36 months)*.............................................. 50%
Blood, blood plasma, blood derivatives and blood
factors .................................................................................................. Covered in full
Nuclear medicine..................................................................................... Covered in full
Renal dialysis .......................................................................................... Covered in full
Hospice services (inpatient and outpatient) ............................................. Covered in full

Infertility services and supplies are described below in the "Infertility services" section.
Sterilization of females and womens contraception methods and counseling, as supported by
HRSA guidelines, are covered under Preventive care in this section.
*A standard hearing aid (analog or digital) is one that restores adequate hearing to the member
and is determined medically necessary and authorized by the members PPG.
Infertility services
Infertility services and supplies (all covered
services that diagnose, evaluate or treat
infertility)............................................................................................. 50%

Infertility services include Prescription Drugs, professional services, inpatient and outpatient care and
treatment by injections.
Infertility services (which include GIFT) and all covered services that prepare the member to receive this
procedure, are covered only for the Health Net member.
Infertility services are covered only for the Health Net member.
Injections for infertility are covered only when provided in connection with services that are covered by this
plan.

Chiropractic services

Benefits are administered by American Specialty Health Plans of California, Inc. (ASH Plans).
Office visits (24-visit maximum per calendar year,
combined with acupuncture) ............................................................... $20
Annual chiropractic appliance allowance .......................................... $50
Acupuncture services

Benefits are administered by American Specialty Health Plans of California, Inc. (ASH Plans).
Office visits (24- visit maximum per calendar year,
combined with chiropractic)................................................................ $20
Limits of coverage
WHATS NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Ambulance and paramedic services that do not result in transportation or that do not meet the criteria for
emergency care, unless such services are medically necessary and prior authorization has been obtained.
Artificial insemination for reasons not related to infertility;
Biofeedback therapy is limited to medically necessary treatment of certain physical disorders such as
incontinence and chronic pain;
Care for mental health care as a condition of parole or probation, or court-ordered testing for mental disorders,
except when such services are medically necessary;
Chiropractic or acupuncture services, except as provided by ASH Plans as shown in the Schedule of benefits
and coverage section of this SB/DF;
Conception by medical procedures (IVF and ZIFT);
Cosmetic services and supplies;
Corrective footwear is not covered unless medically necessary and custom made for the member or is a
podiatric device to prevent or treat diabetes-related complications;
Custodial or live-in care;
Dental services. However, Medically Necessary dental or orthodontic services that are an integral part of
reconstructive surgery for cleft palate procedures are covered. Cleft palate includes cleft palate, cleft lip or
other craniofacial anomalies associated with cleft palate.
Disposable supplies for home use;
Experimental or investigational procedures, except as set out under the "Clinical trials" and "If you have a
disagreement with our plan" sections of this SB/DF;
Genetic testing is not covered except when determined by Health Net to be medically necessary. The
prescribing physician must request prior authorization for coverage;
Marriage counseling, except when rendered in connection with services provided for a treatable mental
disorder. Your employer has independently contracted with Optum, a specialized health care service plan, to
provide mental health and substance abuse benefits;
Non-eligible institutions. This plan only covers services or supplies provided by a legally operated hospital,
Medicare-approved skilled nursing facility or other properly licensed facility as specified in the plans EOC.
Any institution that is primarily a place for the aged, a nursing home or similar institution, regardless of how
it is designated, is not an eligible institution. Services or supplies provided by such institutions are not
covered;
Nontreatable disorders;
Norplant;
Orthoptics (eye exercises);
Outpatient prescription drugs (except as noted under "Prescription drug program");
Personal or comfort items;
Physician self-treatment;
Physician treating immediate family members;
Private rooms when hospitalized, unless medically necessary;
Private-duty nursing;
Refractive eye surgery unless medically necessary, recommended by the member's treating physician and
authorized by Health Net;
Reversal of surgical sterilization;
Routine foot care for treatment of corns, calluses and cutting of nails, unless prescribed for the treatment of
diabetes;
 Routine physical examinations (including psychological examinations or drug screening) for insurance,
licensing, employment, school, camp or other nonpreventive purposes;
Services and supplies not authorized by Health Net, the Behavioral Health Administrator or the physician
group according to Health Net's procedures;
Services for the treatment of chemical dependency (other than detoxification) are not covered. Your employer
has independently contracted with Optum, a specialized health care service plan, to provide mental health and
substance abuse benefits;
Services for a surrogate pregnancy are covered only when the surrogate is a Health Net member. However,
when compensation is obtained for the surrogacy, Health Net shall have a lien on such compensation to
recover its medical expense;
Services received before effective date or after termination of coverage, except as specifically stated in the
"Extension of Benefits" section of the plans EOC;
Services related to education or training, including for employment or professional purposes;
State hospital treatment, except as the result of an emergency or urgently needed care;
Stress, except when rendered in connection with services provided for a treatable mental disorder;
Treatment of jaw joint disorders or surgical procedures to reduce or realign the jaw, unless medically
necessary; and
Treatment of obesity, weight reduction or weight management, except for treatment of morbid obesity.

The above is a partial list of the principal exclusions and limitations applicable to the medical portion of
your Health Net plan. The EOC, which you will receive if you enroll in this plan, will contain the full list.
Benefits and coverage
WHAT YOU PAY FOR SERVICES

The "Schedule of benefits and coverage" section explains your coverage and payment for services. Please take a
moment to look it over.

TIMELY ACCESS TO NON-EMERGENCY HEALTH CARE SERVICES

The California Department of Managed Health Care (DMHC) has issued regulations (Title 28, Section
1300.67.2.2) with requirements for timely access to non-emergency health care services.
You may contact Health Net at the number shown on the back cover, 7 days per week, 24 hours per day to access
triage or screening services. Health Net provides access to covered health care services in a timely manner. For
further information, please refer to the plans EOC or contact the Health Net Customer Contact Center at the
phone number on the back cover.
SPECIAL ENROLLMENT RIGHTS IF YOU LOSE ELIGIBILITY FROM THE ACCESS FOR
INFANTS OR MOTHERS PROGRAM (AIM) OR A MEDI-CAL PLAN

If you become ineligible and lose coverage under the Access for Infants or Mothers Program (AIM) or a Medi-
Cal plan, you are eligible for a special enrollment period in which you and your dependent(s) are eligible to
request enrollment in this plan within 60 days of becoming ineligible and losing coverage from the Access for
Infants and Mothers Program (AIM) or a Medi-Cal plan.

NOTICE OF REQUIRED COVERAGE

Benefits of this plan provide coverage required by the Newborns and Mothers Health Protection Act of 1996
and the Womens Health and Cancer Right Act of 1998.

The Newborns and Mothers Health Protection Act of 1996 sets requirements for a minimum Hospital length of
stay following delivery. Specifically, group health plans and health insurance issuers generally may not, under
Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or
newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean
section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization
from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
The Womens Health and Cancer Right Act of 1998 applies to medically necessary mastectomies and requires
coverage for prosthetic devices and reconstructive surgery on either breast provided to restore and achieve
symmetry.

COVERAGE FOR NEWBORNS

Children born after your date of enrollment are automatically covered at birth. To continue coverage, the child
must be enrolled through your employer before the 30th day of the childs life. If the child is not enrolled within
30 days of the childs birth:

Coverage will end the 31st day after birth; and

You will have to pay your physician group for all medical care provided after the 30th day of your babys life.
If the mother is the Subscribers spouse and an enrolled Member, the child will be assigned to the mother's
Physician Group and may not transfer to another Physician Group until the first day of the calendar month
following the birth. If the mother is not enrolled, the child will be automatically assigned to the Subscribers
Physician Group. If you want to choose another Physician Group for that child, the transfer will take effect only
as stated in the Transferring to Another Contracting Physician Group portion of this section.

EMERGENCIES

Health Net covers emergency and urgently needed care throughout the world. If you need emergency or urgently
needed care, seek care where it is immediately available. Depending on your circumstances, you may seek this
care by going to your physician group or to the nearest emergency facility or by calling 911.

You are encouraged to use appropriately the 911 emergency response system, in areas where the system is
established and operating, when you have an emergency medical condition that requires an emergency response.
All ambulance and ambulance transport services provided as a result of a 911 call will be covered, if the request is
made for an emergency medical condition.

All follow-up care after the urgency has passed and your condition is stable, must be provided or authorized by
your physician group, otherwise, it will not be covered by Health Net.

Emergency care means any otherwise covered service for an acute illness, a new
injury or an unforeseen deterioration or complication of an existing illness, injury or
condition already known to the person or, if a minor, to the minors parent or guardian that
a reasonable person with an average knowledge of health and medicine (a prudent
layperson) would believe requires immediate treatment (including severe mental illness and
serious emotional disturbances of a child), and without immediate treatment, any of the
following would occur: (a) his or her health would be put in serious danger (and in the case
of a pregnant woman, would put the health of her unborn child in serious danger); (b) his or
her bodily functions, organs or parts would become seriously damaged; or (c) his or her
bodily organs or parts would seriously malfunction. Emergency care also includes
treatment of severe pain or active labor. Active labor means labor at the time that either of
the following would occur: (a) there is inadequate time to effect safe transfer to another
hospital prior to delivery; or (b) a transfer poses a threat to the health and safety of the
member or her unborn child. Emergency care will also include additional screening,
examination and evaluation by a physician (or other personnel to the extent permitted by
applicable law and within the scope of his or her license and privileges) to determine if a
psychiatric emergency medical condition exists and the care and treatment necessary to
relieve or eliminate the psychiatric emergency medical condition, either within the
capability of the facility or by transferring the member to a psychiatric unit within a general
acute hospital or to an acute psychiatric hospital as medically necessary.

All air and ground ambulance and ambulance transport services provided as a result of a
911 call will be covered, if the request is made for an emergency medical condition
(including severe mental illness and serious emotional disturbances of a child).

Urgently needed care means any otherwise covered medical service that a reasonable person with an average
knowledge of health and medicine would seek for treatment of an injury, unexpected illness or complication of an
existing condition, including pregnancy, to prevent the serious deterioration of his or her health, but which does not
qualify as emergency care, as defined in this section. This may include services for which a person should reasonably
have known an emergency did not exist.
MEDICALLY NECESSARY CARE

All services that are medically necessary will be covered by your Health Net plan (unless specifically excluded
under the plan). All covered services or supplies are listed in the plans EOC; any other services or supplies are
not covered.

SECOND OPINIONS

You have the right to request a second opinion when:

Your PCP or a referral physician gives a diagnosis or recommends a treatment plan that you are not satisfied
with;
You are not satisfied with the result of treatment you have received;
You are diagnosed with, or a treatment plan is recommended for, a condition that threatens loss of life, limb,
or bodily function, or a substantial impairment, including but not limited to a serious chronic condition; or
Your PCP or a referral physician is unable to diagnose your condition, or test results are conflicting.

When you request a second opinion, you will be responsible for any applicable copayments. To obtain a copy of
Health Nets second opinion policy, call the Customer Contact Center at the phone number on the back cover.

CLINICAL TRIALS

Routine patient care costs for patients diagnosed with cancer who are accepted into phase I, II, III, or IV clinical
trials are covered when medically necessary, recommended by the members treating physician and authorized by
Health Net. The physician must determine that participation has a meaningful potential benefit to the member and
the trial has therapeutic intent. For further information, please refer to the plans EOC.

EXTENSION OF BENEFITS

If you or a covered family member is totally disabled when your employer ends its group services agreement with
Health Net, we will cover the treatment for the disability until one of the following occurs:

A maximum of 12 consecutive months elapses from the termination date;

Available benefits are exhausted;
The disability ends; or
The member becomes enrolled in another plan that covers the disability.

Your application for an extension of benefits for disability must be made to Health Net within 90 days after your
employer ends its agreement with us. We will require medical proof of the total disability at specified intervals.

CONFIDENTIALITY AND RELEASE OF MEMBER INFORMATION

Health Net knows that personal information in your medical records is private. Therefore, we protect your
personal health information in all settings (including oral, written and electronic information). The only time we
would release your confidential information without your authorization is for payment, treatment, health care
operations (including, but not limited to utilization management, quality improvement, disease or case
management programs) or when permitted or required to do so by law, such as for court order or subpoena. We
will not release your confidential claims details to your employer or their agent. Often Health Net is required to
comply with aggregated measurement and data reporting requirements. In those cases, we protect your privacy by
not releasing any information that identifies our members.
PRIVACY PRACTICES

Once you become a Health Net member, Health Net uses and discloses a members protected health information
and nonpublic personal financial information* for purposes of treatment, payment, health care operations, and
where permitted or required by law. Health Net provides members with a Notice of Privacy Practices that
describes how it uses and discloses protected health information; the individuals rights to access, to request
amendments, restrictions, and an accounting of disclosures of protected health information; and the procedures for
filing complaints. Health Net will provide you the opportunity to approve or refuse the release of your
information for non-routine releases such as marketing. Health Net provides access to members to inspect or
obtain a copy of the members protected health information in designated record sets maintained by Health Net.
Health Net protects oral, written and electronic information across the organization by using reasonable and
appropriate security safeguards. These safeguards include limiting access to an individual's protected health
information to only those who have a need to know in order to perform payment, treatment, health care operations
or where permitted or required by law. Health Net releases protected health information to plan sponsors for
administration of self-funded plans but does not release protected health information to plan sponsors/employers
for insured products unless the plan sponsor is performing a payment or health care operation function for the
plan. Health Net's entire Notice of Privacy Practices can be found in the plan's EOC, at www.healthnet.com/uc
under "Privacy" or you may call the Customer Contact Center at the phone number on the back cover of this
booklet to obtain a copy.

* Nonpublic personal financial information includes personally identifiable financial information that you
provided to us to obtain health plan coverage or we obtained in providing benefits to you. Examples include
Social Security numbers, account balances and payment history. We do not disclose any nonpublic personal
information about you to anyone, except as permitted by law.

TECHNOLOGY ASSESSMENT

New technologies are those procedures, drugs or devices that have recently been developed for the treatment of
specific diseases or conditions or are new applications of existing procedures, drugs or devices. New technologies
are considered investigational or experimental during various stages of clinical study as safety and effectiveness
are evaluated and the technology achieves acceptance into the medical standard of care. The technologies may
continue to be considered investigational or experimental if clinical study has not shown safety or effectiveness or
if they are not considered standard care by the appropriate medical specialty. Approved technologies are
integrated into Health Net benefits.

Health Net determines whether new technologies should be considered medically appropriate, or investigational
or experimental, following extensive review of medical research by appropriately specialized physicians. Health
Net requests review of new technologies by an independent, expert medical reviewer in order to determine
medical appropriateness or investigational or experimental status of a technology or procedure.

The expert medical reviewer also advises Health Net when patients require quick determinations of coverage,
when there is no guiding principle for certain technologies or when the complexity of a patients medical
condition requires expert evaluation. If Health Net denies, modifies or delays coverage for your requested
treatment on the basis that it is experimental or investigational, you may request an independent medical review
(IMR) of Health Nets decision from the Department of Managed Health Care. Please refer to the Independent
Medical Review of Grievances Involving a Disputed Health Care Service in the Evidence of Coverage for
additional details.

Utilization management
Utilization management is an important component of health care management. Through the processes of pre-
authorization, concurrent and retrospective review and care management, we evaluate the services provided to our
members to be sure they are medically necessary and appropriate for the setting and time. These processes help to
maintain Health Net's high quality medical management standards.

PRE-AUTHORIZATION

Certain proposed services may require an assessment prior to approval. Evidence-based criteria are used to
evaluate whether or not the procedure is medically necessary and planned for the appropriate setting (that is,
inpatient, ambulatory surgery, etc.).

CONCURRENT REVIEW

This process continues to authorize inpatient and certain outpatient conditions on a concurrent basis while
following a members progress, such as during inpatient hospitalization or while receiving outpatient home care
services.

DISCHARGE PLANNING

This component of the concurrent review process ensures that planning is done for a members safe discharge in
conjunction with the physicians discharge orders and to authorize post-hospital services when needed.

RETROSPECTIVE REVIEW

This medical management process assesses the appropriateness of medical services on a case-by-case basis after
the services have been provided. It is usually performed on cases where pre-authorization was required but not
obtained.

CARE OR CASE MANAGEMENT

Nurse care managers provide assistance, education and guidance to members (and their families) through major
acute and/or chronic long-term health problems. The care managers work closely with members, their physicians
and community resources.

If you would like additional information regarding Health Nets utilization management process, please call the
Health Net Customer Contact Center at the phone number on the back cover.

Payment of fees and charges

YOUR COPAYMENT AND DEDUCTIBLES

The "Schedule of benefits and coverage" section explains your coverage and payment for services. Please take a
moment to look it over.

PREPAYMENT FEES

Your employer will pay Health Net your monthly subscription charges for you and all enrolled family members.
Check with your employer regarding any share that you may be required to pay. If your share ever increases, your
employer will inform you in advance.

OTHER CHARGES

You are responsible for payment of your share of the cost of services covered by this plan. Amounts paid by you
are called copayments, which are described in the "Schedule of benefits and coverage" section of this SB/DF.
Beyond these charges the remainder of the cost of covered services will be paid by Health Net.
When the total amount of copayments you pay equals the out-of-pocket maximum shown in the "Schedule of
benefits and coverage" section, you will not have to pay additional copayments for the rest of the year for most
services provided or authorized by your physician group.

Payment for services not covered by this plan will not count toward the calendar year out-of-pocket
maximum. Additionally, certain deductibles and copayments will not count toward the out-of-pocket
maximum as shown in the "Schedule of benefits and coverage" section. For further information please refer
to the plans EOC.

LIABILITY OF SUBSCRIBER OR ENROLLEE FOR PAYMENT

If you receive health care services without the required referral or authorization from your PCP or physician
group (medical), you are responsible for the cost of these services.

Remember, this plan only covers services that are provided or authorized by a PCP or physician group,
except for emergency or out-of-area urgent care. Consult the Health Net HMO Directory for a full listing of
Health Net-contracted physicians.

REIMBURSEMENT PROVISIONS

Payments that are owed by Health Net for services provided by or through your physician group (medical) will
never be your responsibility.

If you have out-of-pocket expenses for covered services, call the Health Net Customer Contact Center for a claim
form and instructions. You will be reimbursed for these expenses less any required copayment or deductible.
(Remember, you do not need to submit claims for medical services provided by your PCP or physician group.)

If you receive emergency services not provided or directed by your physician group (medical), you may have to
pay at the time you receive service. To be reimbursed for these charges, you should get a complete statement of
the services received and, if possible, a copy of the emergency room report.

Please call the Health Net Customer Contact Center at the phone number on the back cover to obtain claim forms,
and to find out whether you should send the completed form to your physician group (medical) or to Health Net.
Medical claims must be received by Health Net within one year of the date of service to be eligible for
reimbursement.

How to file a claim:

For medical services, please send a completed claim form within one year of the date of service to:

Health Net Commercial Claims

P.O. Box 14702
Lexington, KY 40512

If you need to file a claim for mental disorders and substance abuse emergency services or for services
authorized by Optum, you must use the CMS (HCFA) - 1500 form. Please send the claim to Optum
within one year of the date of service at the address listed on the claims form or to Optum at:
 Optum
P.O. Box 30760
Salt Lake City, UT 84130-0760

Please call Health Nets Customer Contact Center at the phone number on the back cover of this booklet or
visit our website at www.healthnet.com/uc to obtain the claim form.

For outpatient prescription drugs, please send a completed prescription drug claim form to:

Health Net
C/O Caremark
P.O. Box 52136
Phoenix, AZ 85072

Please call Health Nets Customer Contact Center at the phone number on the back cover of this booklet or
visit our website at www.healthnet.com/uc to obtain a prescription drug claim form.

For emergency chiropractic or acupuncture service or for other approved services, please send your
completed claim form within one year of the date of service to:

American Specialty Health Plans of California, Inc.

Attention: Member Services Department
P.O. Box 509002
San Diego, CA 92150-9002

Claims for covered expenses filed more than one year from the date of service will not be paid unless you
can show that it was not reasonably possible to file your claim within that time limit and that you have filed
as soon as was reasonably possible.

PROVIDER REFERRAL AND REIMBURSEMENT DISCLOSURE

If you are considering enrolling in our plan, you are entitled to ask if the plan has special financial arrangements
with our physicians that can affect the use of referrals and other services you may need. Health Net uses financial
incentives and various risk sharing arrangements when paying providers. To get this information, call the Health
Net Customer Contact Center at the phone number on the back cover. You can also contact your physician group
or your PCP to find out about our physician payment arrangements.

Facilities
Health care services for you and eligible members of your family will be provided at:

The facilities of the physician group you chose at enrollment; or

A nearby Health Net-contracted hospital, if hospitalization is required.

Many Health Net contracting physician groups have either a physician on call 24 hours a day or an urgent care
center available to offer access to care at all times.

The physician group you choose will also have a contractual relationship with local hospitals (for acute, subacute
and transitional care) and skilled nursing facilities. These are listed in your Health Net HMO Directory.
PHYSICIAN GROUP TRANSFERS

You may switch doctors within the same physician group at any time. You may also transfer to another physician
group monthly. Simply contact Health Net by the 15th of the month to have your transfer effective by the 1st of
the following month. If you call after the 15th, your transfer will be effective the 1st of the second following
month.
Transfer requests will generally be honored unless you are confined to a hospital. (However, Health Net may
approve transfers under this condition for certain unusual or serious circumstances. Please contact the Health Net
Customer Contact Center at the phone number on the back cover of this booklet.)

CONTINUITY OF CARE

Transition of Care for New Enrollees

You may request continued care from a provider who does not contract with Health Net if at the time of your
enrollment with Health Net you were receiving care for the conditions listed below. Health Net may provide
coverage for completion of services from a non-participating provider, subject to applicable copayments and any
exclusions and limitations of your plan. You must request the coverage within 60 days of your group's effective
date unless you can show that it was not reasonably possible to make the request within 60 days of the group's
effective date and you make the request as soon as reasonably possible. The non-participating provider must be
willing to accept the same contract terms applicable to providers currently contracted with Health Net, who are
not capitated and who practice in the same or similar geographic region. If the provider does not accept such
terms, Health Net is not obligated to provide coverage with that provider.
Continuity of Care Upon Termination of Provider Contract
If Health Nets contract with a physician group or other provider ends, Health Net will transfer any affected
members to another contracted physician group or provider to ensure that care continues. Health Net will provide
a written notice to affected members at least 60-days prior to termination of a contract with a physician group or
an acute care hospital to which members are assigned for services. For all other hospitals that end their contract
with Health Net, a written notice will be provided to affected members within five days after the effective date of
the contract termination.
Health Net may provide coverage for completion of services from a provider whose contract has ended, subject to
applicable copayments and any other exclusions and limitations of your plan and if such provider is willing to
accept the same contract terms applicable to the provider prior to the providers contract termination. You must
request continued care within 30 days of the providers date of termination, unless you can show that it was not
reasonably possible to make the request within 30 days of the providers date of termination and you make the
request as soon as it is reasonably possible.
You may request continued care from a provider whose contract is terminated if at the time of termination the
member was receiving care from such a provider for the conditions listed below.
The following conditions are eligible for continuation of care:
An acute condition;
A serious chronic condition not to exceed twelve months;
A pregnancy (including the duration of the pregnancy and immediate postpartum care);
A newborn (up to 36 months of age, not to exceed twelve months);
A terminal illness (through the duration of the terminal illness);
A surgery or other procedure that has been authorized by Health Net (or by the members prior health plan for
new enrollee) as part of a documented course of treatment.
In addition, you may request continued care from a provider, including a hospital, if you have been enrolled in
another Health Net HMO plan that included a larger network than this plan, Health Net will offer the same scope
of continuity of care for completion of services, regardless of whether you had the opportunity to retain your
current provider by selecting either:

A Health Net product with an out of network benefit;

A different Health Net HMO network product that included your current provider; or
Another health plan or carrier product.

If you would like more information on how to request continued care or to request a copy of Health Net's
continuity of care policy, please call the Health Net Customer Contact Center at the phone number on the back
cover.

Renewing, continuing or ending coverage

RENEWAL PROVISIONS

The contract between Health Net and your employer is usually renewed annually. If your contract is amended or
terminated, your employer will notify you in writing.

INDIVIDUAL CONTINUATION OF BENEFITS

Please examine your options carefully before declining coverage.

If your employment with your current employer ends, you and your covered family members may qualify for
continued group coverage under:

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): For most groups with 20 or more
employees, COBRA applies to employees and their eligible dependents, even if they live outside of
California. Please check with your group to determine if you and your covered dependents are eligible.

Cal-COBRA Continuation Coverage: If you have exhausted COBRA and you live in the Health Net
Service Area, you may be eligible for additional continuation coverage under state Cal-COBRA law. This
coverage may be available if you have exhausted federal COBRA coverage, have had less than 36 months of
COBRA coverage, and you are not entitled to Medicare. If you are eligible, you have the opportunity to
continue group coverage under this plan through Cal-COBRA for up to 36 months from the date that federal
COBRA coverage began.

USERRA Coverage: Under a federal law known as the Uniformed Services Employment and
Reemployment Rights Act (USERRA), employers are required to provide employees who are absent from
employment to serve in the uniformed services and their dependents who would lose their group health
coverage the opportunity to elect continuation coverage for a period of up to 24 months. Please check with
your group to determine if you are eligible.

Also, you may be eligible for continued coverage for a disabling condition (for up to 12 months) if your employer
terminates its agreement with Health Net. Please refer to the "Extension of benefits" section of this SB/DF for
more information.
TERMINATION OF BENEFITS

The following information describes circumstances when your coverage in this plan may be terminated. For a
more complete description of termination of benefits, please see the plans EOC.

Termination for Nonpayment of Subscription Charges

Your coverage under this plan ends when the agreement between the employer and Health Net terminates due to
nonpayment of the subscription charges by the employer. Health Net will provide your employer a 30-day grace
period to submit the delinquent subscription charges. If your employer fails to pay the required subscription
charges by the end of the 30-day grace period, the agreement between Health Net and your employer will be
cancelled and Health Net will terminate your coverage at the end of the grace period.

Termination for Loss of Eligibility

Your coverage under this plan ends on the date you become ineligible. Some reasons that you may lose eligibility
in this plan include, but are not limited to, the following situations:

The agreement between the employer covered under this plan and Health Net ends;
You cease to either live or work within Health Nets service area; or
You no longer work for the employer covered under this plan.

Termination for Cause

Coverage under this Health Net plan may be terminated for good cause with a 30-day written notice for a member
who commits any act or practice, which constitutes fraud, or for any intentional misrepresentation of material fact
under the terms of the agreement, including:

Misrepresenting eligibility information about yourself or a dependent;

Presenting an invalid prescription or physician order;
Misusing a Health Net Member I.D. Card (or letting someone else use it); or
Failing to notify us of changes in family status that may affect your eligibility or benefits.

We may report criminal fraud and other illegal acts to the authorities for prosecution.

How to Appeal Your Termination

You have a right to file a complaint if you believe that your coverage is improperly terminated or not renewed. A
complaint is also called a grievance or an appeal. Refer to the "If You Have a Disagreement With Our Plan"
section for information about how to appeal Health Net's decision to terminate your coverage.

If your coverage is terminated based on any reason other than for nonpayment of subscription charges and your
coverage is still in effect when you submit your complaint, Health Net will continue your coverage until the
review process is completed, subject to Health Net's receipt of the applicable subscription charges. You must also
continue to pay the deductible and copayments for any services and supplies received while your coverage is
continued during the review process.

If your coverage has already ended when you submit your request for review, Health Net is not required to
continue coverage. However, you may still request a review of Health Net's decision to terminate your coverage
by following the complaint process described in the "If You Have a Disagreement With Our Plan" section.

If the person involved in any of the above activities is the enrolled employee, coverage under this plan will
end as well for any covered dependents.
If you have a disagreement with our plan
The provisions referenced under this title as described below are applicable to services and supplies covered under
this SB/DF. The California Department of Managed Health Care is responsible for regulating health care service
plans.

If you have a grievance against Health Net, you should first telephone Health Net at 1-800-539-4072 and use the
plans grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit
any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an
emergency, or a grievance that has not been satisfactorily resolved by Health Net, or a grievance that has
remained unresolved for more than 30 days, you may call the Department for assistance.

You may also be eligible for an independent medical review (IMR). If you are eligible for IMR, the IMR process
will provide an impartial review of medical decisions made by a health plan related to the Medical Necessity of a
proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature
and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone
number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The
Department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms
and instructions online.

MEMBER GRIEVANCE AND APPEALS PROCESS

If you are dissatisfied with the quality of care that you have received or feel that you have been incorrectly denied
a service or claim, you may file a grievance or appeal.

How to file a grievance or appeal:

You may call the Customer Contact Center at the phone number on the back cover or submit a Member
Grievance Form through the Health Net website at www.healthnet.com/uc:

You may also write to: Health Net of California

P.O. Box 10348
Van Nuys, CA 91410-0348

Please include all the information from your Health Net identification card as well as details of your
concern or problem.

Health Net will acknowledge your grievance or appeal within five calendar days, review the information and tell
you of our decision in writing within 30 days of receiving the grievance. For conditions where there is an
immediate and serious threat to your health, including severe pain or the potential loss of life, limb or major
bodily function, Health Net will notify you of the status of your grievance no later than three days from the receipt
of all the required information. For urgent grievances, Health Net will immediately notify you of the right to
contact the Department of Managed Health Care. There is no requirement that you participate in Health Nets
grievance process prior to applying to the Department of Managed Health Care for review of an urgent grievance.

In addition, you can request an independent medical review of disputed health care services from the
Department of Managed Health Care if you believe that health care services eligible for coverage and
payment under the plan was improperly denied, modified or delayed by Health Net or one of its contracting
providers.
 Also, if Health Net denies your appeal of a denial for lack of medical necessity, or denies or delays
coverage for requested treatment involving experimental or investigational drugs, devices, procedures or
therapies, you can request an independent medical review of Health Nets decision from the Department of
Managed Health Care if you meet the eligibility criteria set out in the plans EOC.

ARBITRATION

If you are not satisfied with the result of the grievance hearing and appeals process, you may submit the problem
to binding arbitration. Health Net uses binding arbitration to settle disputes, including medical malpractice. When
you enroll in Health Net, you agree to submit any disputes to arbitration, in lieu of a jury or court trial.

Additional plan benefit information

The following plan benefits show benefits available with your plan. For a more complete description of
copayments, and exclusions and limitations of service, please see the plans EOC.

Behavioral health services

Your employer has independently contracted with Optum, a specialized health care service plan, to provide
mental health and substance abuse benefits. Covered services may be obtained by receiving a referral through
Optum at 1-888-440-8225.
Care must be provided by an Optum participating provider and approved by Optum. Special provisions apply in
the event of an emergency, and are described in detail in the Optum Evidence of Coverage (EOC).
Additional benefits are provided for those Members having a diagnosis categorized as Severe Mental Illness.
Please contact Optum at 1-888-440-8225 for a complete schedule of your Mental Health and substance abuse
Benefits.

Prescription drug program

Health Net contracts with many major pharmacy chains, supermarket based pharmacies and privately owned
neighborhood pharmacies in California. For a complete and up-to-date list of participating pharmacies, please
visit our website at www.healthnet.com/uc or call the Health Net Customer Contact Center at the phone number
on the back cover.

UC WALK-UP SERVICE THROUGH UC MEDICAL CENTER PHARMACIES

To streamline access to prescription medications, Health Net and the UC Medical Center Pharmacies have
partnered to offer UC members with the ability to fill up to a 90-day prescription for maintenance medications
at any of the UC designated Medical Center Pharmacies. Just like Health Nets current Mail Order Program,
members can now obtain up to a 90-day supply for only two copays, at one of the UC-designated Medical
Center pharmacies.

PRESCRIPTIONS BY MAIL DRUG PROGRAM

If your prescription is for a maintenance medication (a drug that you will be taking for an extended period),
you have the option of filling it through our convenient Prescriptions By Mail Drug Program or from a CVS
retail pharmacy. This program allows you to receive a 90-consecutive-calendar-day supply of maintenance
medications for only two copays. For complete information, call the Health Net Customer Contact Center at
the phone number on the back cover.

Schedule II narcotic drugs (which are drugs that have a high abuse risk as classified by the Federal Drug
Enforcement Administration) are not covered through mail order.

THE HEALTH NET COMMERCIAL FORMULARY

This plan uses the Commercial Formulary. The Health Net Commercial Formulary is the approved list of
medications covered for illnesses and conditions. It was developed to identify the safest and most effective
medications for Health Net members while attempting to maintain affordable pharmacy benefits.

We specifically suggest to all Health Net contracting PCPs and specialists that they refer to this Commercial
Formulary when choosing drugs for patients who are Health Net members. When your physician prescribes
medications listed in the Commercial Formulary, it ensures that you are receiving a high quality prescription
medication that is also of high value.

The Commercial Formulary is updated regularly, based on input from the Health Net Pharmacy and Therapeutics
(P&T) Committee. The Committee members are actively practicing physicians of various medical specialties and
clinical pharmacists. Voting members are recruited from contracting physician groups throughout California
based on their experience, knowledge and expertise. In addition, the P&T Committee frequently consults with
other medical experts to provide additional input to the Committee. Updates to the Commercial Formulary and
drug usage guidelines are made as new clinical information and new drugs become available. In order to keep the
Commercial Formulary current, the P&T Committee evaluates clinical effectiveness, safety and overall value
through:

Medical and scientific publications;

Relevant utilization experience; and
Physician recommendations.

To obtain a copy of Health Nets most current Commercial Formulary, please visit our web site at
www.healthnet.com/uc or call the Health Net Customer Contact Center at the phone number on the back cover.

WHAT IS "PRIOR AUTHORIZATION?"

Some drugs require prior authorization. This means that your doctor must contact Health Net in advance to
provide the medical reason for prescribing the medication. You may obtain a list of drugs requiring prior
authorization by visiting our website at www.healthnet.com/uc or call the Health Net Customer Contact Center at
the phone number on the back cover.

How to request prior authorization:

Requests for prior authorization may be submitted by telephone or facsimile. . Urgent requests from
physicians for authorization are processed as soon as possible, not to exceed 72 hours after Health Nets
receipt of the request and any additional information requested by Health Net that is reasonably necessary to
make the determination.

Routine requests from physicians are processed in a timely fashion, not to exceed 5 days, as appropriate and
medically necessary, for the nature of the members condition after Health Nets receipt of the information
reasonably necessary and requested by Health Net to make the determination.
 Upon receiving your physicians request for prior authorization, Health Net will evaluate the information
submitted and make a determination based on established clinical criteria for the particular medication. The
criteria used for prior authorization are developed and based on input from the Health Net P&T Committee
as well as physician specialist experts. Your physician may contact Health Net to obtain the usage guidelines
for specific medications.

If authorization is denied by Health Net, you will receive written communication including the specific reason for
denial. If you disagree with the decision, you may appeal the decision.

The appeal may be submitted in writing, by telephone or through e-mail. We must receive the appeal within 60
days of the date of the denial notice. Please refer to the plans EOC for details regarding your right to appeal.

To submit an appeal:

Call the Health Net Customer Contact Center at the phone number on the back cover;
Visit www.healthnet.com/uc for information on e-mailing the Customer Contact Center; or
Write to: Health Net Customer Contact Center
P.O. Box 10348
Van Nuys, CA 91410-0348

WHATS COVERED

Please refer to the "Schedule of benefits and coverage" section of this SB/DF for the explanation of covered
services and copayments.

This plan covers the following:

Level I drugs - Drugs listed as Level I on the Commercial Formulary that are not excluded from coverage
(primarily generic);

Level II drugs Drugs listed as Level II on the Commercial Formulary that are not excluded from coverage
(primarily brand name and diabetic supplies, including insulin); and

Level III drugs - Drugs listed on the Commercial Formulary as Level III or drugs that are not listed on the
Commercial Formulary.

Preventive drugs and womens contraceptives

MORE INFORMATION ABOUT DRUGS THAT WE COVER

Prescription drug covered expenses are the lesser of Health Nets contracted pharmacy rate or the pharmacys
retail price for covered prescription drugs.

Prescription drug refills are covered, up to a 30-consecutive-day supply per prescription at a Health Net
contracted pharmacy for one copayment. A copayment is required for each prescription. In some cases, a 30-
consecutive-calendar-day supply of medication may not be an appropriate drug treatment plan according to
the Food and Drug Administration (FDA) or Health Nets usage guidelines. If this is the case, the amount of
medication dispensed may be less than a 30-consecutive-calendar-day supply.

If the pharmacys retail price is less than the applicable copayment, the member will only pay the pharmacys
retail price.

Percentage copayments will be based on Health Nets contracted pharmacy rate.

 Mail order drugs are covered up to a 90-consecutive-calendar-day supply. When the retail pharmacy
copayment is a percentage, the mail order copayment is the same percentage of the cost to Health Net as the
retail pharmacy copayment.

Prescription drugs for the treatment of asthma are covered as stated in the Commercial Formulary. Inhaler
spacers and peak flow meters under the pharmacy benefit are covered when medically necessary. Nebulizers
(including face masks and tubing) are covered under "Durable Medical Equipment" and educational programs
for the management of asthma are covered under "Patient Education" through the medical benefit. For
information about copayments required for these benefits, please see the "Schedule of benefits and coverage"
section of this SB/DF.

Preventive drugs, including smoking cessation drugs, are prescribed over-the-counter drugs or prescription
drugs that are used for preventive health purposes per the U.S. Preventive Services Task Force A and B
recommendations. Covered contraceptives are FDA-approved contraceptives for women that are either
available over-the-counter or are only available with a prescription. Vaginal, oral, transdermal and emergency
contraceptives are covered under this pharmacy benefit. IUD, implantable and injectable contraceptives are
covered (when administered by a physician) under the medical benefit. Refer to the plans EOC for more
information.

Diabetic supplies (blood glucose testing strips, lancets, needles and syringes) are packaged in 50, 100 or 200
unit packages. Packages cannot be "broken" (that is, opened in order to dispense the product in quantities
other than those packaged). When a prescription is dispensed, you will receive the size of package and/or
number of packages required for you to test the number of times your physician has prescribed for up to a 30-
day period. For more information about diabetic equipment and supplies, please see "Endnotes" in the
"Schedule of benefits and coverage" section of this SB/DF.

Self-injectable drugs (other than insulin) are considered specialty drugs and must be obtained through a
contracted specialty pharmacy vendor. Specialty Drugs require Prior Authorization and upon approval, the
specialty pharmacy vendor will arrange for the dispensing of the drugs. Please refer to the plan's EOC for
additional information.

WHATS NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Services or supplies excluded under pharmacy services may be covered under the medical benefits portion
of your plan. In addition to the exclusion and limitations listed below, prescription drug benefits are subject
to the plans general exclusions and limitations. Consult the plans EOC for more information.

Allergy serum is covered as a medical benefit. See "allergy serum" benefit in the "Schedule of benefits and
coverage" for details;

Coverage for devices is limited to vaginal contraceptive devices, peak flow meters, spacer inhalers and
diabetic supplies. No other devices are covered even if prescribed by a participating physician;

Drugs prescribed for the treatment of obesity are covered, when medically necessary for the treatment of
morbid obesity. In such cases, the drugs will be subject to prior authorization from Health Net;

Drugs or medicines administered by a physician or physicians staff member;

Drugs prescribed for routine dental treatment;

Drugs prescribed to shorten the duration of the common cold;

 Drugs prescribed for sexual dysfunction when not medically necessary, including drugs that establish,
maintain, or enhance sexual function or satisfaction;

Experimental drugs (those that are labeled "Caution - Limited by Federal Law to investigational use only"). If
you are denied coverage of a drug because the drug is investigational or experimental you will have a right to
independent medical review. See "If you have a disagreement with our plan" section of this SB/DF for
additional information;

Hypodermic needles or syringes, except for insulin needles, syringes and specific brands of pen devices;

Immunizing agents, injections (except for insulin), agents for surgical implantation, biological sera, blood,
blood derivatives or blood plasma obtained through a prescription;

Individual doses of medication dispensed in plastic, unit dose or foil packages unless medically necessary or
only available in that form;

Limits on quantity, dosage and treatment duration may apply to some drugs. Medications taken on an "as-
needed" basis may have a copayment based on a specific quantity, standard package, vial, ampoule, tube, or
other standard unit. In such a case, the amount of medication dispensed may be less than a 30-consecutive-
calendar-day supply. If medically necessary, your physician may request a larger quantity from Health Net;

Medical equipment and supplies (including insulin), that are available without a prescription are covered
when prescribed by a physician for the management and treatment of diabetes or for preventive purposes in
accordance with the U.S. Preventive Services Task Force A and B recommendations or for female
contraception as approved by the FDA. Any other nonprescription drug, medical equipment or supply that can
be purchased without a prescription drug order is not covered even if a physician writes a prescription drug
order for such drug, equipment or supply. However, if a higher dosage form of a prescription drug or over-
the-counter (OTC) drug is only available by prescription, that higher dosage drug will be covered. If a drug
that was previously available by prescription becomes available in an OTC form in the same prescription
strength, then any prescription drugs that are similar agents and have comparable clinical effect(s) will only
be covered when medically necessary and prior authorization is obtained from Health Net;

Prescription drugs filled at pharmacies that are not in the Health Net pharmacy network or are not in
California except in emergency or urgent care situations;

Prescription drugs prescribed by a physician who is not a member physician or an authorized specialist are
not covered, except when the physicians services have been authorized, or because of a medical emergency
condition, illness or injury, for urgently needed care or as specifically stated;

Replacement of lost, stolen or damaged medications;

Supply amounts for prescriptions that exceed the FDAs or Health Nets indicated usage recommendation are
not covered unless medically necessary and prior authorization is obtained from Health Net; and

Drugs prescribed for a condition or treatment not covered by this plan are not covered. However, the plan
does cover drugs for medical conditions that result from nonroutine complications of a noncovered service.

This is only a summary. Consult the plans EOC to determine the exact terms and conditions of your
coverage.
Chiropractic care program
Health Net has partnered with American Specialty Health Plans of California, Inc. (ASH Plans) to offer quality
and affordable chiropractic coverage. With this program, you are free to obtain this care by selecting a contracted
chiropractor from our ASH Plans Contracted Chiropractor Directory. Although you are always welcome to
consult your PCP, you will not need a referral to see a contracted chiropractor.

WHATS COVERED

Please refer to the "Schedule of benefits and coverage" section of this SB/DF for the explanation of covered
services and copayments.

Office visits;
Chiropractic items such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and
home traction units prescribed by a ASH Plans contracted chiropractor and approved by ASH Plans; and
All covered chiropractic services require pre-approval from ASH Plans except for a new patient examination
by a contracted chiropractor and emergency chiropractic services.

WHATS NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Services or supplies excluded under the chiropractic care program may be covered under the medical benefits
portion of your plan. Consult the plan's EOC for more information.

Air conditioners, air purifiers, therapeutic mattresses, vitamins, minerals, nutritional supplements, durable
medical equipment, appliances or comfort items;
Charges for hospital confinement and related services;
Charges for anesthesia;
Conjunctive physical therapy not associated with spinal, muscle or joint adjustment;
Diagnostic scanning, MRI, CAT scans or thermography;
Exams or treatment of strictly non-neuromusculoskeletal disorders;
Experimental or investigational chiropractic services. Only chiropractic services that are non-investigational,
proven and meet professionally recognized standards of practice in the chiropractic provider community are
covered. ASH Plans will determine what will be considered experimental or investigational;
Hypnotherapy, behavioral training, sleep therapy, weight programs, educational programs, nonmedical self-
help or self-care, or any self-help physical exercise training;
Lab tests, x-rays, adjustments, physical therapy or other services not chiropractically necessary or classified as
experimental;
Pre-employment physicals or vocational rehabilitation arising from employment or covered under any public
liability insurance;
Treatment for temporomandibular joint syndrome (TMJ);
Treatment or services not authorized by ASH Plans or delivered by an ASH Plans contracted provider (except
emergency chiropractic services or upon a referral to a non-contracted provider approved by ASH Plans).

This is only a summary. Consult the plans EOC to determine the exact terms and conditions of your
coverage.
Acupuncture care program
Health Net has partnered with American Specialty Health Plans of California, Inc. (ASH Plans) to offer quality
and affordable acupuncture coverage. Although you are always welcome to consult your PCP, you will not need a
referral to see a contracted acupuncturist.

With this program, you are free to obtain care by self-referring to a contracted acupuncturist from the ASH Plans
Contracted Acupuncturist Directory. All covered services require pre-approval by ASH Plans except for:

A new patient examination by a contracted acupuncturist and the provision or commencement, in the new
patient examination, of medically necessary services that are covered acupuncture services, to the extent
consistent with professionally recognized standards of practice; and
Emergency acupuncture services.

When ASH Plans approves a treatment plan, the approved services for the subsequent office visits covered by the
treatment plan include not only the approved services but also a re-examination in each subsequent office visit, if
deemed necessary by the contracted acupuncturist, without additional approval by ASH Plans.

DEFINITION OF ACUPUNCTURE COVERED SERVICES

Medically necessary services provided by a contracted acupuncturist (or a non-contracted acupuncturist, when
emergency acupuncture services are provided or a referral is approved by ASH Plans) for the following injuries,
illnesses, diseases, functional disorders or conditions, when determined medically necessary.

WHATS COVERED

Please refer to the "Schedule of benefits and coverage" section of this SB/DF for the explanation of covered
services and copayments.

This plan covers office visits for treatment of the following conditions:
Neuromusculoskeletal conditions, including conditions such as fibromyalgia and myofascial pain
Pain, including low back pain, post-operative pain, and post-operative dental pain
Nausea, including adult post-operative nausea and vomiting, chemotherapy nausea and vomiting, and nausea
of pregnancy
Carpal tunnel syndrome
Headaches
Menstrual cramps
Osteoarthritis
Stroke rehabilitation
Tennis elbow

WHATS NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Services or supplies excluded under the acupuncture care program may be covered under the medical benefits
portion of your plan. Consult the plan's EOC for more information.

Devices, personal and comfort items;

 Diagnostic scanning, MRI, CAT scans or thermography;
X-ray second opinions;
Exams or treatment other than for neuromusculoskeletal conditions, pain, nausea, or other covered conditions,
as described under the definition of acupuncture services above;
Treatment for asthma or addiction (including but not limited to drugs, alcohol, nicotine addiction, or smoking
cessation);
Hypnotherapy, behavioral training, sleep therapy, weight programs, educational programs, self-help items or
services, or physical exercise training;
Physical therapy services classified as experimental or investigational;
Physicals or vocational rehabilitation for employment or those covered under any public liability insurance
Experimental or investigational acupuncture services. Only acupuncture services that are non-investigational,
proven and meet professionally recognized standards of practice in the acupuncture provider community are
covered. ASH Plans will determine what will be considered experimental or investigational;
Charges for hospital confinement and related services;
Charges for anesthesia; and
Treatment or services not authorized by ASH Plans or not delivered by a contracted acupuncturist when
authorization is required; treatment not delivered by a contracted acupuncturist (except emergency
acupuncture services or upon referral to a non-contracted acupuncturist approved by ASH Plans).

This is only a summary. Consult the plans EOC to determine the exact terms and conditions of your
coverage.
Notice of language service
Contact us
Health Net
Post Office Box 9103
Van Nuys, California 91409-9103

Customer Contact Center

Large Group (for companies with 51 or more employees):
1-800-539-4072 HMO

1-800-331-1777 (Spanish)
1-877-891-9053 (Mandarin)
1-877-891-9050 (Cantonese)
1-877-339-8596 (Korean)
1-877-891-9051 (Tagalog)
1-877-339-8621 (Vietnamese)

Telecommunications Device for the Hearing and Speech Impaired

1-800-995-0852
www.healthnet.com/uc

Health Net of California, Inc., is a subsidiary of Health Net, Inc.

Health Net is a registered service mark of Health Net, Inc. All rights reserved.

SBID: 86065 86065