| Medical Procedure |
Health Net
|
|
|
Not Eligible for Medicare
|
Enrolled in Medicare
"Senority Plus"
|
| Annual Deductible |
None
|
None
|
| Annual Co-Payment Limit on Allowable Charges |
Plan pays 100% after co-payments reach $1,500 in a year ($4,500 for a family) |
Plan pays 100% after co-payments reach $1,500 in a year ($4,500 for a family) |
| Overall Lifetime Maximum |
None
|
None
|
| Hospital |
|
|
|
|
You pay $400 per admission |
Plan pays 100% |
|
|
Plan pays 100% |
Plan pays 100% |
| Extended Care Facility (Skilled Nursing) |
You pay $400 per admission, 100 days maximum |
Plan pays 100%, 100 days maximum |
| Physician Services - Routine Physical |
|
|
|
|
You pay $20 per visit |
You pay $5 per visit |
Inpatient Surgery
|
Plan pays 100% |
Plan pays 100% |
Outpatient Surgery
|
Plan pays 100% (You pay $20 for office visit) |
Plan pays 100% (You pay $5 for office visit) |
Hospital Visits
|
Plan pays 100% |
Plan pays 100% |
Office Visits
|
You pay $20 per visit |
You pay $5 per visit |
| Diagnostic X-Ray and Lab |
Plan pays 100% (You pay $20 for office visit) |
Plan pays 100% (You pay $5 for office visit) |
| Durable Medical Equipment |
Plan pays 100% |
Plan pays 100% |
| Home Nursing Care |
Plan plays 100% for first 31 visits, You pay $20 per visit thereafter |
Plan plays 100% for first 31 visits, You pay $10 per visit thereafter |
| Physical Therapy |
Plan pays 100%; maximum of 60 days per medical condition |
You pay $5 per visit |
| Speech Therapy |
Plan pays 100%; maximum of 60 days per medical condition |
You pay $5 per visit |
| Chiropractic Care |
Not covered
|
You pay $5 per visit, maximum of 20 visits per calendar year |
| Hearing Aids |
Not covered
|
Not covered
|
| Substance Abuse - |
|
|
|
|
Plan pays 100%; maximum of 30 days |
Plan pays 100% |
|
|
You pay $15 per group session, or $30 per individual session; maximum of 20 visits |
You pay $20 per visit, maximum of 30 visits |
| Psychiatric Care - |
|
|
|
|
You pay $400 per admission; 30 days maximum |
Plan pays 100% per visit, maximum of 190 days per lifetime |
|
|
You pay $30 per visit; maximum of 20 visits, unlimited visits for severe conditions |
You pay $20 per visit; maximum of 30 visits |
| Prescription Drugs |
Must be obtained at a participating HMO pharmacy
|
|
|
You pay $10 per generic and $25 per brand name, and $35 per non-preferred prescription; maximum of a 30-day supply |
You pay $6 per generic and $12 per brand name prescription, maximum of 30-day supply |
Maintenance (30 day supply or more thru the Mail Order)
|
Mail order - you pay 2 co-pays per prescription for a 90-day supply |
Mail order - You pay 2 co-pays per prescription, up to a 90-day supply |
| Vision Care |
You pay $20 for exam; lenses & frames not covered |
You pay $5 for exam; $100 frame allowance, one pair every 2 years |
| Dental Care |
Not Covered
|
You pay $5 per office visit, plus additional co-payments per procedure (Refer to Dental Brochure) |
| Ambulance |
Plan pays 100% |
Plan pays 100% |
| Emergency Room Care |
You pay $35 (co-payment waived if admitted to hospital) |
You pay $20 (co-payment waived if admitted to hospital) |
