Health Net Seniority Plus
(Medicare Advantage HMO)
The information in this chart is intended as a high-level summary only. The information about the HMOs or the insured products contained in an applicable Evidence of Coverage (EOC) or service provider agreement between Pacific Gas and Electric Company and the HMO or service provider shall govern in case of conflict between this chart and the EOC or service provider agreement.
If you enroll in Health Net Seniority Plus, you will receive an EOC, free of charge. It describes Seniority Plus' benefit provisions, claims procedures, provider network, and other rules in detail. If you need additional information, including a list of participating network providers, you can contact Seniority Plus directly.
The information contained in this summary is informational only. No right shall accrue to you and/or your dependents because of any statement of error, or in omission from, this summary. The Health Net Seniority Plus HMO's EOC is the binding document between the health plan and its members.
Summary Chart
This summary chart describes benefits as of January 1, 2013.
Provisions
Health Net Seniority Plus
(Medicare Advantage HMO)
General
  • Must use Health Net Seniority Plus HMO network providers
  • No annual deductible
  • No annual out-of-pocket maximum
  • No lifetime benefit maximum
  • No pre-existing condition exclusions
Hospital Stay
No charge
Skilled Nursing Facility
No charge, 100-day limit per benefit period; no prior hospital stay required; excludes custodial care
Emergency Room Care
$25 copay/visit for emergencies (waived if admitted); must notify PCP within 48 hours
Outpatient Hospital Care
$10 copay/visit
Office Visits
  • $10 copay/office visit
  • $10 copay/home visit
Urgent Care Visits
$10 copay/visit
Routine Physical Examinations
$10 copay/visit
Immunizations and Injections
  • Immunizations (age 18 and older) — no charge
  • Allergy testing and allergy injections — no charge for Medicare-covered services
Eye Examinations
$10 copay/visit for screening; lenses and frames not covered
X-rays and Lab Tests
No charge
Pre-Admission Testing
No charge
Home Health Care
No charge
Hospice Care
No charge
Outpatient Physical Therapy
No charge
Durable Medical Equipment
No charge; see plan EOC for limitations and exclusions
Chiropractic Care
$10 copay/visit for Medicare-approved chiropractic services
Acupuncture
Discounts available; contact Member Services for details
Hearing Aids and related expenses
Covered effective January 1, 2014
80% for Medically Necessary only; one hearing aid per ear every three years
Other Benefits
  • Hearing exams for each Medicare-covered exam (up to 1 routine hearing test each year) — $10 copay/visit
  • Foot care if medically necessary — $10 copay/visit
Prescription Drug Benefits
When you and your dependents are enrolled in Health Net Seniority Plus, Health Net Seniority Plus' Part D Prescription Drug Plan provides your retail and mail-order prescription drug coverage, not Express Scripts. For specific information about drug coverage through Health Net Seniority Plus's Part D Prescription Drug Plan, contact Health Net Seniority Plus directly.
Provisions
Health Net Seniority Plus
(Medicare Advantage HMO)
General
Retail and mail-order Medicare Part D prescription drug plans are administered by Health Net Seniority Plus
Annual Prescription Drug Deductible (separate from medical Plan deductible)
None
Annual Prescription Drug Out-of-Pocket Maximum
None
Annual or Lifetime Prescription Drug Maximum Benefit Limit
None
Retail Purchases
Medicare Part D plan
Up to 30-day supply — you pay:
  • $5/generic
  • $15/brand formulary
  • $35/non-formulary
Some drugs require pre-authorization
Mail-Order Purchases
Medicare Part D plan
For up to 90-day supply — you pay:
  • $10/generic
  • $30/brand formulary
  • $70/non-formulary
Open formulary
Infertility, Sexual Dysfunction, Memory Enhancement and Contraceptive Drugs
Call Health Net for details
Mental Health and Substance Abuse (MHSA) Benefits
The following chart provides an overview of Mental Health and Substance Abuse (MHSA) benefits for Health Net Seniority Plus plan members. These benefits are administered both by Health Net Seniority Plus and by ValueOptions, depending on the type of care you receive.
When care is provided by ValueOptions:
  • Pre-authorization is required for inpatient and hospital stays. Care that is not medically necessary will not be covered.
For more information on benefits provided by ValueOptions, refer to the Mental Health and Substance Abuse Coverage section.
Provisions
Health Net Seniority Plus
(Medicare Advantage HMO)
General
Health Net Seniority Plus's general medical plan provisions also apply to Mental Health and Substance Abuse benefits
Outpatient Mental Health
  • $10 copay/visit
  • No visit limit
Inpatient Mental Health
No charge; no day limit
Outpatient Substance Abuse
$10 copay/visit
Coverage for Eligible Expenses* through ValueOptions, not the HMO; requires referral by ValueOptions
  • $10 copay/visit (individual)
  • $5 copay/visit (group)
  • No visit limit
Inpatient Substance Abuse
No charge
Coverage for Eligible Expensed* through ValueOptions, not the HMO; requires referral by ValueOptions
  • 100%
  • No limit on number of stays
* Coverage for Eligible Expenses. "Eligible Expenses" are: (1) expenses for Covered Health Services that are covered by the plan; (2) those that ValueOptions considers "Medically Necessary" for diagnosis or treatment; and (3) those that do not exceed the "Usual and Customary" rate as determined by ValueOptions. Any costs not meeting this definition are the responsibility of the member. For additional information or questions, call ValueOptions.
Other Information
Eligible Dependents and Member Rights
Refer to the complete description of eligibility, COBRA rights, Qualified Medical Child Support Order procedures and rights, ERISA rights and information, plan funding and plan continuation provided elsewhere in this Summary of Benefits Handbook.
Choice of Providers
Members must select a contracting Physician Group where the member wants to receive medical care. That Physician Group will provide or authorize all medical care. Family members may select different contracting Physician Groups. However, each person must select a contracting Physician Group close enough to his or her residence to allow reasonable access to medical care. In addition to selecting a contracting Physician Group, each member must choose a Primary Care Physician from the Physician Group. The Primary Care Physician provides and coordinates medical care. Providers are neither employed nor exclusively contracted by the HMO.
Plan Telephone Numbers
800-275-4737 (current members)
800-596-6565 (prospective members)
Website
www.healthnet.com/pge