Page 6 - JONS EE Guide 08-18 - final English

BENEFITS

Medical Insurance

Health Net Health Net Health Net
Plan Name Salud HMO Plan ExcelCare EOA PPO
Network Name SIMNSA Salud HMO PPO CA PPO Non-Network
(Mexico) (California)
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Calendar Year)
- Individual $0 $0 $0 $0 $2,000 $2,000
- Family $0 $0 $0 $0 $6,000 $6,000
Co-Insurance (Plan Pays) 100% 70% 80% 80% 70% 50%
Office Visit Copay
- Primary Care Physician $5 Copay $30 Copay $30 Copay $50 Copay $30 Copay Ded, 50%
- Specialist Office Visit $5 Copay $30 Copay $30 Copay $50 Copay $30 Copay Ded, 50%
Out-of-Pocket Maximum
- Individual $2,000 $1,500 $4,500 $4,000 $8,000
- Family $6,000 $4,500 $9,000 $8,000 $24,000

Hospitalization
- Inpatient No Charge 30% 20% Not covered Ded, 30% Ded, 50%
- Outpatient No Charge 30% 20% Not covered Ded, 30% Ded, 50%
Emergency Services $10 Copay $50 Copay $100 Copay $100 Copay $100 Copay, $100 Copay,
30% 30%
Urgent Care $10 Copay $30 Copay $30 Copay $30 Copay $30 Copay + $30 Copay +
Ded Ded

Preventive Care No Charge No Charge No Charge No Charge No Charge Not Covered
Outpatient Rehabilitation $5 Copay $30 Copay $30 Copay $50 Copay Ded, 30% Ded, 50%
(Physical, Occupational or
Speech)
Pharmacy Benefits

Deductible (Calendar Year)
- Individual $0 $100 Medical CY Ded. Applies
- Family $0 $100 Per Member Medical CY Ded. Applies
Out-of-Pocket Maximum
- Individual $2,000 $2,000 $2,000
- Family $4,000 $4,000 $4,000
Retail Pharmacy
- Generic Formulary $5 Copay $5 Copay $15 Copay $15 Copay $15 Copay $15 Copay+50%
- Brand Name Formulary $5 Copay $25 Copay Ded, $30 Copay Ded, $30 Copay $30 Copay $30 Copay+50%
- Non-Formulary $5 Copay $45 Copay Ded, $50 Copay Ded, $50 Copay $50 Copay $50 Copay+50%
- Supply Limit—Up to 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary Not Covered $10 Copay $30 Copay $30 Copay $30 Copay Not Covered
- Brand Name Formulary Not Covered $62.50 Copay $60 Copay $60 Copay $60 Copay Not Covered
- Non-Formulary Not Covered $112.50 Copay $100 Copay $100 Copay $100 Copay Not Covered
- Supply Limit—Up to Not Covered 90 Days 90 Days 90 Days 90 Days N/A

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