PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Health Net
CMS Rating
Plan Type
HMO SNP
Annual Deductible
$310.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$6,700 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$28.10
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Coming Soon
Coming Soon
Inpatient Mental Health Care
Coming Soon
Coming Soon
Skilled Nursing Facility (SNF)
Coming Soon
Coming Soon
Home Health Care
$0 maximum per visit
Not Applicable
Doctor Office Visits
20% maximum per visit
Not Applicable
Outpatient Services
20% maximum per visit
Not Applicable
Ambulance Services
20% maximum
Not Applicable
Emergency Care
20% maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Kidney Disease and Conditions
20% maximum per visit
Not Applicable
Specialist Office Visit
20% maximum per visit
Not Applicable

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

$0 yearly deductible for Medicare Part B drugs.*

0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.*


Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://https://www.healthnet.com/medicare/pharmacy on the web.

Different out-of-pocket costs may apply for people who
  • have limited incomes,
  • live in long term care facilities, or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.


The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from Health Net Seniority Plus Amber II (HMO SNP) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Health Net Seniority Plus Amber II (HMO SNP) approves the exception, you will pay the generic cost share for generic drugs and the brand cost share for brand drugs.

In-Network

You pay a $0 annual deductible.

Initial Coverage

Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either:
  • A $0 copay; or
  • A $1.20 copay; or
  • A $2.55 copay
For all other drugs, either:
  • A $0 copay; or
  • A $3.60 copay; or
  • A $6.35 copay.


Tier 1: Preferred Generic $0 copay for drugs in this tier

Tier 6: Select Care Drugs $0 copay for drugs in this tier

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

  • one-month (30-day) supply


  • two-month (60-day) supply


  • three-month (90-day) supply


Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

  • one-month (34-day) supply of drugs



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s):

  • one-month (30-day) supply


  • two-month (60-day) supply


  • three-month (90-day) supply


Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay a $0 copay.

Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Health Net Seniority Plus Amber II (HMO SNP).

You can get out-of-network drugs the following way:

  • one-month (30-day) supply


Out-of-Network Initial Coverage

Depending on your income and institutional status, you will be reimbursed by Health Net Seniority Plus Amber II (HMO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either:
  • A $0 copay; or
  • A $1.20 copay; or
  • A $2.55 copay
For all other drugs purchased out-of-network, either:
  • A $0 copay; or
  • A $3.60 copay; or
  • A $6.35 copay.


Tier 1: Preferred Generic $0 copay for drugs in this tier

Tier 6: Select Care Drugs $0 copay for drugs in this tier

Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed in full for drugs purchased out-of-network.


Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

You must go to network doctors, specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).


Inpatient Hospital Care



In-Network

Plan covers 90 days each benefit period.

You will not be charged additional cost sharing for professional services.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Outpatient Care

Inpatient Mental Health Care



In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Skilled Nursing Facility (SNF)



General

Authorization rules may apply.

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

You will not be charged additional cost sharing for professional services


Home Health Care



General

Authorization rules may apply.

In-Network

$0 copay for each Medicare-covered home health visit*


Hospice



General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


Doctor Office Visits



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for each Medicare-covered primary care doctor visit.*

0% or 20% of the cost for each Medicare-covered specialist visit.*


Outpatient Medical Services and Supplies

Chiropractic Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for each Medicare-covered chiropractic visit*

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


Podiatry Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for each Medicare-covered podiatry visit*

$0 copay for up to 12 supplemental routine podiatry visit(s) every year

Medicare-covered podiatry visits are for medically necessary foot care.


Outpatient Mental Health Care



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for each Medicare-covered individual therapy visit*

0% or 20% of the cost for each Medicare-covered group therapy visit*

0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist*

0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist*

0% or 20% of the cost for Medicare-covered partial hospitalization program services*


Outpatient Substance Abuse Care



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits*

0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits*


Outpatient Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit*

0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit*


Ambulance Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered ambulance benefits.*


Emergency Care



General

0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits*

$50,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.

If you are immediately admitted to the hospital, you pay $0 for the emergency room visit.


Urgently Needed Care



General

0% or 20% of the cost for Medicare-covered urgently-needed-care visits*

If you are immediately admitted to the hospital, you pay $0 for the urgently-needed-care visit.


Outpatient Rehabilitation Services



General

Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

In-Network

0% or 20% of the cost for Medicare-covered Occupational Therapy visits*

0% or 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits*


Durable Medical Equipment



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered durable medical equipment*


Preventive Services

Prosthetic Devices



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered prosthetic devices*

0% or 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices*


Diabetes Programs and Supplies



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered Diabetes self-management training*

0% or 20% of the cost for Medicare-covered Diabetes monitoring supplies*

0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts*

Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies.


Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered lab services*

0% or 20% of the cost for Medicare-covered diagnostic procedures and tests*

0% or 20% of the cost for Medicare-covered X-rays*

0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)*

0% or 20% of the cost for Medicare-covered therapeutic radiology services*


Cardiac and Pulmonary Rehabilitation Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services*

0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services*

0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services*


Additional Benefits

Preventive Services



General

Authorization rules may apply.

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

Plan covers a physical exam annually.


Kidney Disease and Conditions



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered renal dialysis*

$0 copay for Medicare-covered kidney disease education services*


Dental Services



In-Network

0% or 20% of the cost for Medicare-covered dental benefits*

$0 copay for supplemental oral exams

$0 copay for up to 2 supplemental cleaning(s) every year

$0 copay for up to 2 supplemental fluoride treatment(s) every year

$0 copay for supplemental dental x-rays

Plan offers additional supplemental comprehensive dental benefits.


Hearing Services



General

Authorization rules may apply.

In-Network

0% or 20% of the cost for Medicare-covered diagnostic hearing exams*

$0 copay for up to 1 supplemental routine hearing exam(s) every year

$0 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every three years

$0 copay each for up to 2 supplemental hearing aid(s) every three years

$2,000 plan coverage limit for supplemental hearing aids every three years.


Vision Services



In-Network

0% or 0% to 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk*

$0 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery*

$0 copay for up to 1 pair(s) of eyeglasses (lenses and frames) every two years

$0 copay for up to 1 pair(s) of contact lenses every two years

$0 copay for up to 1 pair(s) of eyeglass lenses every two years

$0 copay for up to 1 frame(s) every two years

$100 plan coverage limit for supplemental eyewear every two years


Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$13 copay$13 copay$13 copay
Tier 3: Preferred Brand Name$45 copay$45 copay$45 copay
Tier 4: Non-Preferred Brand Name$95 copay$95 copay$95 copay
Tier 5: Specialty Tier25% coinsurance25% coinsurance25% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$0 copay$0 copay
Tier 2: Non-Preferred Generic$39 copay$39 copay$26 copay
Tier 3: Preferred Brand Name$135 copay$135 copay$125 copay
Tier 4: Non-Preferred Brand Name$285 copay$285 copay$275 copay
Tier 5: Specialty Tier25% coinsurance25% coinsurance25% coinsurance

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Care for older adults – functional status assessment
Care for older adults – Pain screening
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

Physician Finder

Physicians that accept Health Net Seniority Plus Amber II (HMO SNP) for California

/
MULL, JOHN
4425 SOUTH CENTRAL AVE
LOS ANGELES, CA 90011
BAHARI-NEJAD, PEJMAN
4425 S CENTRAL AVE
LOS ANGELES, CA 90011
KASHANI, HOUMAN
747 WAREHOUSE ST
LOS ANGELES, CA 90021
BLEAKLEY, DENNIS
515 E. 5TH STREET
LOS ANGELES, CA 90021
GREGERSON, PAUL
515 E. 5TH ST
LOS ANGELES, CA 90021
LARA, AGUSTIN
1005 E WASHINGTON BLVD
LOS ANGELES, CA 90021
HU, JAMES
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
TRIPATHY, DEBASISH
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
PRESS, MICHAEL
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
SPICER, DARCY
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
EL-KHOUEIRY, ANTHONY
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
QUINN, DAVID
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
RUSSELL, CHRISTY
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
LIEBMAN, HOWARD
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
DUNN, MATTHEW
1510 SAN PABLO STREET
LOS ANGELES, CA 90033
IQBAL, SYMA
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
GINSBERG, DAVID
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
BOYD, STUART
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
WANG, LINA
1500 SAN PABLO ST
LOS ANGELES, CA 90033
SHERROD, ANDY
1500 SAN PABLO ST
LOS ANGELES, CA 90033
NICHOLS, PETER
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
MARTIN, SUE
1500 SAN PABLO STREET
LOS ANGELES, CA 90039
LAI, ROSE
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
STREETER, OSCAR
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
SCHUCKMAN, ANNE
1441 EASTLAKE AVE
LOS ANGELES, CA 90089
Details
JOHN MULL, MD MPH
Phone Number
(323) 908-4219
Office Locations
4425 SOUTH CENTRAL AVE
LOS ANGELES, CA 90011
4425 SOUTH CENTRAL AVE LOS ANGELES CA, 90011

Community Q&A

Do you have questions about this plan?

Get answers from the HealthPocket community.
1 question| 1 answer
Dental
Q:How do I acquire a list of Dentist in Hemet/San Jacinto California.
Asked by Greg 

1 answer

Know the Answer? Answer this Question
A: Currently on our website, we only have the tools for you to locate the network providers, as for network dentists, you may try the following link for more information: https://www.healthnet.com/portal/member/providerSearch.action
Answered on 2/9/2014 by davina

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