You are eligible to enroll in Health Net Seniority Plus Sapphire Premier (HMO) if:

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1 H3561_19_7831SB_002_M Accepted

2 This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at ca.healthnetadvantage.com. You are eligible to enroll in Health Net Seniority Plus Sapphire Premier (HMO) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Health Net Seniority Plus Sapphire (HMO) service area counties). Our service area includes the following counties in California: Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in a Health Net commercial or group health plan, or a Medicaid plan.) For Health Net Seniority Plus Sapphire Premier (HMO) you can join if eligible for Medicare or Medicaid in California. If you are enrolled in the California Medicaid Plan (Medi-Cal) then: Premiums, copays,, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of California for full dual eligible enrollees. Please contact the plan for further details. The Health Net Seniority Plus Sapphire Premier (HMO) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-todate list of network providers, visit ca.healthnetadvantage.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Health Net Seniority Plus Sapphire Premier (HMO) will be responsible for the costs.) This Health Net Seniority Plus Sapphire Premier (HMO) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source. Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

3 Summary of Benefits JANUARY 1, 2019 DECEMBER 31, 2019 Benefits Health Net Seniority Plus Sapphire Premier (HMO) H3561:002 Premiums / Copays / Coinsurance With Health Net Seniority With Health Net Seniority Plus Sapphire (HMO) Plus Sapphire (HMO) and Medicare and full Medicare only, you pay Medicaid/ Medi-Cal eligibility, you pay Monthly Plan Premium $0 $34.80 Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage* Outpatient Hospital* Doctor Visits* Your premium is based on your low income subsidy status. $0 deductible for covered medical services $0 - $85 deductible for Part D prescription drugs (applies to drugs on Tiers 2, 3,4 and 5) $0 deductible for inpatient hospital stay $6,700 annually $0 deductible for covered medical services $285 deductible for Part D prescription drugs (applies to drugs on Tiers 2,3,4 and 5) $1,340 deductible for inpatient hospital stay (may change in 2019) This is the most you will pay in copays and for covered medical services for the year. $0 copay per stay In 2018, the amounts for each benefit period were: Outpatient Hospital (includes ambulatory surgical center and observation services) 0% per visit Primary Care: $0 copay per visit Specialist: $0 copay per visit $ 1,340 hospital deductible each benefit period $0 copay per days 1 through 60 $ 335 copay per day for days 61 through 90 $ 670 copay per day per lifetime reserve day (may change in 2019) Outpatient Hospital (includes ambulatory surgical center and observation services) 20% per visit Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

4 Benefits Preventive Care* (e.g. flu vaccine, diabetic screening) Health Net Seniority Plus Sapphire Premier (HMO) H3561:002 Premiums / Copays / Coinsurance With Health Net Seniority Plus Sapphire (HMO) Medicare and full Medicaid/ Medi-Cal eligibility, you pay $0 copay Other preventive services are available. With Health Net Seniority Plus Sapphire (HMO) and Medicare only, you pay Emergency Care 0% per visit $0 copay per visit Urgently Needed Services 20% per visit Diagnostic Services/Labs/ Imaging* Hearing Services* Dental Services* Vision Services* Lab services: $0 copay Diagnostic tests and procedures: 0% Outpatient X-ray services: 0% Diagnostic Radiological services: 0% Hearing exam (Medicarecovered): 0% Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Dental services (Medicarecovered): 0% per visit Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment and X-rays) You do not have to pay the copay if admitted to the hospital immediately. 20% (up to $65) per visit Lab services: $0 copay Diagnostic tests and procedures: 20% Outpatient X-ray services: 20% Diagnostic Radiological services: 20% Hearing exam (Medicarecovered): 20% Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Dental services (Medicarecovered): 20% per visit Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment, and X-rays) Comprehensive dental services: Additional comprehensive dental benefits are available. Vision exam (Medicare-covered): $0 copay per visit Routine eye exam: $0 copay per visit (up to 1 every calendar year) Routine eyewear: up to $550 allowance every 2 calendar years Mental Health Services* Individual and group therapy: 0% per visit Individual and group therapy: 20% per visit Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

5 Benefits Health Net Seniority Plus Sapphire Premier (HMO) H3561:002 Premiums / Copays / Coinsurance With Health Net Seniority Plus Sapphire (HMO) Medicare and full Medicaid/ Medi-Cal eligibility, you pay With Health Net Seniority Plus Sapphire (HMO) and Medicare only, you pay Skilled Nursing Facility * $0 copay per stay For each benefit period, you pay: $0 copay per day, days 1 through 20 $ copay per day, days 21 through 100 (may change for 2019) Physical Therapy* $0 copay per visit Ambulance* 0% (per one-way trip) 20% (per one-way trip) Transportation* $0 copay for each one-way trip (Up to 40 one-way trips to plan-approved locations.) Medicare Part B Drugs* Chemotherapy drugs: 0% Other Part B drugs: 0% Chemotherapy drugs: 20% Other Part B drugs: 20% Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

6 Deductible Phase Initial Coverage Phase (after you pay your Part D deductible, if applicable) Part D Prescription Drugs $0 - $285 deductible (Deductible does not apply to Tiers 1 and 6.) With Health Net, Seniority Plus Sapphire Medicare and full Medicaid/ Medi-Cal eligibility, you pay Standard Retail Rx 30-day supply Tier 1: Preferred Generic $0 or $1.25 or $3.40 copay $0 copay With Health Net Seniority Plus Sapphire, Medicare and full Medicaid/ Medi- Cal eligibility, you pay Mail-Order Rx 90-day supply Tier 2: Generic $0 or $3.80 or $8.50 copay $60 copay Tier 3: Preferred Brand $0 or $3.80 or $8.50 copay $141 copay Tier 4: Non-Preferred Drug $0 or $3.80 or $8.50 copay $300 copay Tier 5: Specialty $0 or $1.25 or $3.40 copay Not available Tier 6: Select Care Drugs $0 or $3.80 or $8.50 copay $0 copay Important Info: Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail-Order, Long- Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific costsharing and the phases of the benefit, please call us or access our EOC online. Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

7 Additional Covered Benefits Benefits Over-the-Counter (OTC) Items Health Net Seniority Plus Sapphire Premier (HMO) H3561: 002 Premiums / Copays / Coinsurance $0 copay ($55 allowance per quarter for items available via mail order) Please visit the plan s website to see the list of covered over-thecounter items. Chiropractic Care* Chiropractic services (Medicare-covered): $0 copay per visit Routine chiropractic services: $0 copay per visit (30 visits per year combined with acupuncture) Acupuncture* Acupuncture: $0 copay per visit (30 visits per year combined with routine chiropractic) Medical Equipment/ Supplies* Durable Medical Equipment (e.g., wheelchairs, oxygen): 0% Prosthetics (e.g., braces, artificial limbs): 0% Diabetic supplies: 0% Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% Prosthetics (e.g., braces, artificial limbs): 20% Diabetic supplies: 20% Foot Care * (Podiatry Services) Foot exams and treatment (Medicare-covered): $0 copay per visit Routine foot care: $0 copay per visit (12 visits per year.) Wellness Programs Fitness program: $0 copay 24-hour nurse advice line: $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

8 Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

9 Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

10 Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

11 For more information, please contact: Health Net Seniority Plus Sapphire Premier (HMO) PO Box Van Nuys, CA ca.healthnetadvantage.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This information is not a complete description of benefits. Call TTY 711 for more information. Coinsurance is the percentage you pay of the total cost of certain medical and prescription drug services. This document is available in other formats such as Braille, large print or audio. The provider network may change at any time. You will receive notice when necessary. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. SBS020843EK00 (07/18) Services with an * (asterisk) may require prior authorization and / or a referral from your doc

12 2019 Part D Model LIS Premium Summary Table for Those Receiving Extra Help HEALTH NET COMMUNITY SOLUTIONS, INC./ Sapphire Premier (HMO) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help. Your level of extra help Monthly Premium for Sapphire Premier (HMO)* 100% $0 75% $ % $ % $26.10 *This does not include any Medicare Part B premium you may have to pay. Health Net Seniority Plus Sapphire Premier (HMO) s premium includes coverage for both medical services and prescription drug coverage. If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Member/Customer Services at , TTY: 711 from From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays. Health Net Seniority Plus Sapphire Premier (HMO) is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net Seniority Plus Sapphire Premier (HMO) depends on contract renewal. You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/ or copayments/ may change on January 1 of each year. ALL_19_8963LTR_C_ H3561_002

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