HEALTH NET PK HEALTH PLAN KNOWLEDGE a simple guide to using your health plan 2008 What s your PK? Just turn the page, find your plan and boost your PK!
Your Dedicated, Toll-Free Line to the Source Health Net s Customer Contact Center Exclusively for The Home Depot Associates You can call 1-800-847-3991, 8:00 a.m. to 6:00 p.m., Monday Friday to speak to a trained Health Net representative whose No. 1 job is to assist The Home Depot associates such as you. Feel free to call whenever you need benefits clarification or have a question about your prescription coverage or any aspect of your plan. After you enroll in Health Net, fill out the information for your plan and medical contact information on the cards below. Then just pop out these cards and place them where you can find them when you need them. In your wallet On your refrigerator door Next to your phone at work or at home In your car s glove compartment CALL US WE LL BE GLAD TO SERVE YOU! Please note: this info card does not replace your Health Net membership identification card, which you will receive after you enroll. Member Information Card Member Information Call Health Net s Customer Contact Center for The Home Depot: 1-800-847-3991 Hours: 8:00 a.m. 6:00 p.m., Monday Friday Plan type: HMO POS Physician name: Physician tel. number: Physician group tel. number: Member Information Call Health Net s Customer Contact Center for The Home Depot: 1-800-847-3991 Hours: 8:00 a.m. 6:00 p.m., Monday Friday Plan type: HMO POS Physician name: Physician tel. number: Physician group tel. number:
Health Net subscriber ID number: In case of life-threatening emergency, call 911. If your situation is serious but not an emergency, call your doctor or physician group. In all cases, contact your doctor as soon as you are able. Visit Health Net at www.healthnet.com/homedepot. Please note: this info card does not replace your Health Net membership identification card, which you will receive after you enroll. Health Net subscriber ID number: In case of life-threatening emergency, call 911. If your situation is serious but not an emergency, call your doctor or physician group. In all cases, contact your doctor as soon as you are able. Visit Health Net at www.healthnet.com/homedepot. Please note: this info card does not replace your Health Net membership identification card, which you will receive after you enroll.
It s all here the information you need to use your Health Net health care plan. Whether you have Health Net HMO or SELECT POS, look inside to have your questions answered on: Membership advantages Benefits Accessing care Copayments and coinsurance Prescription coverage Maternity And more! This guide presents highlights of Health Net s plans for The Home Depot associates. It is not intended as a comprehensive benefits and services document. For full information on Health Net medical benefits and covered services, including exclusions and limitations, consult your Evidence of Coverage, which you will receive after you enroll.
Table of contents HEALTH NET MEMBER ADVANTAGES Member programs 1 Online programs 2 FOR ALL ASSOCIATES Choose your health plan 3 How does an HMO work? 4 How does a Point-of-Service (POS) plan work? 5 Your ID Card never leave home without it! 6 Why it s important to check your ID cards when you receive them 6 HMO and POS ID card samples 8 Health Net Prescription Drug Benefit 16 Three levels of prescription coverage 16 Getting a prescription filled 18 Prescription Drug Mail Order Program 19 Health Net Recommended Drug List 20 Brand and generic medications 21 Prescription Prior Authorization 22 Questions to ask your doctor or pharmacist to make best use of your Prescription Drug Benefit 23 If your physician group should close 24 FOR ASSOCIATES CHOOSING HMO COVERAGE Your HMO benefits at a glance 25 Obtaining care with your HMO plan 26 Building a positive relationship with your doctor and doctor s office staff 27 The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot
Your primary care physician 28 Choosing a primary care physician 28 Changing your primary care physician 29 Seeing a specialist 29 Seeing a specialist without a referral 29 What if I get a bill or statement? 30 Maternity pregnancy and childbirth coverage 31 Emergency and urgent care 32 FOR ASSOCIATES CHOOSING POS COVERAGE Your SELECT POS benefits at a glance 33 The SELECT POS three-tier system 35 Obtaining care with your POS plan 36 Choosing a primary care physician 36 Precertification ensuring your safety 37 Selecting physicians and specialists with the POS plan 38 Changing your SELECT 1 primary care physician 38 Maternity pregnancy and childbirth coverage 39 Emergency and urgent care 40 GLOSSARY Get your questions answered here! 41 Where to go for additional information Inside back cover Health Net / The Home Depot Customer Contact Card Inside back cover PK TIP If you run into a term you don t understand, check the Glossary on page 41 to see if it s explained there, or call the Customer Contact Center at 1-800-847-3991. The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
HEALTH NET MEMBER ADVANTAGES Above and beyond added value from your Health Net membership HELPING OUR MEMBERS STAY HEALTHY WITH SERVICE THAT PUTS YOU FIRST Maybe you or a covered family member have an ongoing health concern, like asthma, heart disease or diabetes. Maybe you ve been diagnosed with breast or prostate cancer, or face an upcoming surgery for back pain. Now is the time to learn more and discover your options. Decision Power SM is designed to help you work closely with your doctor in choosing a treatment course that is right for you. Decision Power includes the following services: Specially trained Health Coaches: Nurses, dieticians and respiratory therapists available 24 hours a day by phone or email Video testimonials from others who have faced the same surgery or procedure Chronic condition support guides Decision Power is complimentary for members and available 24 hours a day. Login to www.healthnet.com/homedepot > It s Your Life Wellsite > Get Decision Support. It s Your Life SM Wellsite, in partnership with WebMD, gives you easy access to the information you need to make smart choices about your health and health coverage. You will find a variety of powerful and easy-to-use tools from trusted sources of health and medical information such as: Condition Centers that provide current, reliable information about specific health care problems from life-threatening conditions like heart disease, diabetes and cancer to chronic problems like allergies and back pain. Wellness Programs such as Quitting Matter SM which helps members quit smoking by providing help and support every step of the way and Pregnancy Matters SM where expectant moms can get free information and advice on how to have a healthy baby. Plus, we ll give you a fee gift upon completion of this program. Dedicated Customer Contact Center, 1-800-847-3991: Toll-free line just for The Home Depot associates with Health Net, we re here to respond to your benefits and coverage questions. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 1
Online programs at www.healthnet.com/homedepot HEALTH NET S HEALTH RESOURCES Decision Power this decision-support service gives members 24-hour access to the guidance and expertise of Health Coaches. Decision Power Health Coaches are specially trained health care professionals (such as nurses, respiratory therapists and dietitians), that can provide the fact-based information and human support you need when you are facing a significant medical decision. Health Risk Questionnaire is an online assessment tool created to help you better understand your health and recognize possible health risks, such as heart disease and diabetes. After completing the survey you will receive an instant personalized health profile to share with your doctor. Hospital Comparison Report: A confidential, personalized online tool that compares hospitals with the highest quality service for a particular procedure. The report allows members to become better informed to ask the right questions and make good decisions with their doctor. Medical Group Comparison Report: This online tool allows Health Net members to compare HMO physician groups based on the quality of care and service the groups provide members. You can gather essential comparative information in four areas: access to care, member satisfaction, managing chronic illness and prescribing practice. OTHER POWERFUL ONLINE RESOURCES Doctor Search: Find the right doctor for you close to work or home. Online Customer Contact Center: Submit your questions online to a customer service representative anytime, day or night, on any Health Net-related topic and receive a response by email! Online consideration filing: Health Net members can now request consideration for concerns about medical care provided by contracted care providers, as well as coverage reconsiderations of a service or claim, simply by filing a form through the Health Net website. Ordering materials: Health Net members can order the following materials: Rx by Mail brochure, prescription claim form and chiropractic directory. 2 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES It s time to choose your health care plan! HOW DO I CHOOSE? You have three choices: HMO Standard, HMO Basic and SELECT POS (point-of-service). WHAT ARE THE DIFFERENCES BETWEEN MEDICAL PLAN OPTIONS? The three main differences are: How much you pay for coverage through payroll deductions. How much you pay out-of-pocket for deductibles, copays and/or coinsurance. Whether or not you can go to out-of-network providers and receive benefits. Read on to learn more about the differences between HMO and POS to decide what s best for you! HMO Basic or Standard POS Three plans in one Select the level of benefit you want each time you seek care SELECT 1 SELECT 2 SELECT 3 HMO PPO Out-of-network Lowest out-of- Lower out-of- Higher out-of- Highest out-ofpocket costs pocket costs pocket costs pocket costs No claim forms No claim forms Claim forms may Claim forms be necessary always required Comprehensive Your Health Net You can refer You can use coverage is Primary Care yourself any physician coordinated by Physician to any doctor you choose, your Health Net coordinates in Health Net s but you will Primary Care all care PPO network have higher Physician out-of-pocket costs The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 3
HMO HOW DOES THE HMO (HEALTH MAINTENANCE ORGANIZATION) PLAN WORK? To receive benefits under a Health Net HMO plan, you must select a primary care physician within the Health Net network. (Health Net s HMO consists of a network of contracted physicians throughout California.) You then see your primary care physician for care and care coordination (referrals to specialists). You must receive care and care coordination from your primary care physician in order to receive benefits for your services. You must contact your primary care physician before you receive initial treatment from a hospital or specialists, except when you receive emergency, mental health or chiropractic care, or visit an OB/GYN within your primary care physician s physician group. It s best to confirm that your primary care physician is still in the Health Net network before you receive care. Any services you receive outside of your primary physician group are not covered unless they are emergency services, or authorized by your physician group. WHAT ARE THE ADVANTAGES OF USING AN HMO? To begin with, you have no paperwork or claims forms. Everything is handled behind the scenes for you. You can also expect copayments for office visits and prenatal, postnatal and newborn care to be the same set amount each time. Health Net s HMOs also provide emergency coverage worldwide, as well as preventive care and health education. 4 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES Select POS HOW DOES A POINT OF SERVICE (POS) PLAN WORK? Your POS plan provides you more choice when selecting how to receive health care services. This is because you have the flexibility to choose the level of benefits you want each time you need care. With POS plans, everyone must select a primary care physician. You can choose to use your primary care physician and receive the highest benefits with no deductibles (SELECT 1 level), or use the added freedom to see other doctors for a higher cost (SELECT 2 or 3 level). The choice is yours. Services are covered at three levels, so it s like having three plans in one! Each covered member of your family can use any level at any time it s your choice. PK TIP Find more information on plan comparisons and benefits in the Benefits At A Glance charts at the beginning of the HMO and POS sections. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 5
6 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES Your ID card never leave home without it! After you enroll, Health Net will mail you an ID card for yourself and every covered member of your family. WHEN YOU GET IT, REVIEW IT CAREFULLY! Your Health Net ID card is loaded with important information. When you sign up with Health Net, you select a primary care physician for you and all covered members of your family. When you receive your cards, you will find your primary care physician s name, address and phone number on the left side of the front panel. Check to make sure the right physician s name is on each card! WHAT IF IT S NOT? It might be a mistake or the doctor you selected may not be available. Call Health Net Customer Contact Center at 1-800-847-3991 if you would like to select a primary care physician other than the one shown on your ID card. The faster you review your card and correct any errors by calling Health Net, the fewer problems you will have when you need to see a doctor! WHY IS MY HEALTH NET ID CARD IMPORTANT? Keep your ID card with you all the time! It has information you need every time you visit your doctor. It will help you get the best care in case of emergency. Be sure to show your ID card each time you access care or have a prescription filled. PK TIP Whether you enroll in HMO or POS, you will receive just one card per member to use in all situations. Please enroll in a timely manner so your cards will not be delayed. If you have not received your cards by your first day of coverage, call the Health Net Customer Contact Center at 1-800-847-3991. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 7
HEALTH NET HMO ID CARD 2 4 5 1 3 6 7 FRONT LEFT PANEL 1. Participating Physician Group (PPG) name this is the physician group your primary care physician belongs to. 2. PPG phone number 3. Primary care physician name 4. Primary care physician address and phone number 5. Effective Date with PPG this notes your first date of coverage with this physician group. 6. PPG ID number your physician group s identifying number. 7. Office, emergency room and prescription copays this is what you pay out of pocket for these services. 8 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES 8 9 13 10 12 11 14 15 16 17 18 FRONT RIGHT PANEL 8. Policy issue date this is the date your policy with Health Net went into effect. 9. Group name your employer and the name of the plan you are enrolled in. 10. Subscriber name The Home Depot associate in whose name this account was established. 11. Member number your identifying number. 12. Member name your name. 13. Subscriber ID the primary identifying number for this account. 14. Group number your employer s identification number. 15. Plan name this names your specific plan type. 16. Rerate month the date your policy renews. 17. Customer Contact Center number 18. Physician and other providers information line, inpatient admission line, electronic claim submission information line for your doctor s use. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 9
HEALTH NET HMO ID CARD (CONTINUED) 19 20 BACK LEFT PANEL 19. Plan mailing address for claim submission. 20. Note to the subscriber 10 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES 21 22 23 24 BACK RIGHT PANEL 21. MHN (mental health and chemical dependency benefit) member contact line 22. What to do in case of emergency 23. Emergency information for doctors and other health care providers 24. Decision Power telephone number to access a Health Coach 24 hours a day, seven days a week The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 11
HEALTH NET SELECT POS ID CARD 1 3 2 4 5 6 7c 7a 7b 7d 8 7e FRONT LEFT PANEL 1. Participating Physician Group (PPG) name this is the physician group your SELECT 1 doctor belongs to. 2. PPG ID number your physician group s identifying number. 3. PPG address and phone number 4. Effective date with PPG this notes your first date of coverage with this physician group. 5. Primary care physician name 6. Primary care physician phone number 7. Contact information for SELECT POS plan a. Mailing address b. Electronic Claims number c. Member Services number d. Line for physicians and other providers e. Health Net website 8. Pharmacist information line for your doctor or pharmacy s use. 12 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES 13 14 10 11 9 15 16 17 12 18 FRONT RIGHT PANEL 9. Group name your employer and the name of the plan you are enrolled in. 10. Subscriber name The Home Depot associate in whose name this account was established. 11. Member name your name. 12. Plan ID this specifies your specific plan type. 13. Policy issue date this is the date your policy with Health Net went into effect. 14. Renewal month the date your policy renews. 15. Group number your employer s identification number. 16. Subscriber number the primary identifying number for this account. 17. Relation to subscriber 18. Member effective date the date your coverage under this policy begins. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 13
HEALTH NET SELECT POS ID CARD (CONTINUED) 19 20 BACK LEFT PANEL 19. Benefit chart 20. MHN (mental health and chemical dependency benefit) member contact line 14 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES 21 22 BACK RIGHT PANEL 21. Precertification: obtaining certification for specific services, including contact number. 22. What to do in case of emergency The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 15
Health Net Prescription Drug Program WHAT S SO GREAT ABOUT MY PRESCRIPTION BENEFIT? Here are several things that set your prescription benefit apart: No deductible on prescriptions Simple copayments for generic and brand name drugs on Health Net s Recommended Drug List Money-saving mail order program for maintenance medications receive up to a 90-day supply by mail! Three levels of coverage to maximize quality and value WHAT IS MY PHARMACY BENEFIT? Health Net covers drugs your doctor prescribes for you (with certain limitations) 1. We pay a part of the cost of each prescription you receive under your health plan. Your share of cost is called your copayment. You have three levels of benefits in your prescription plan: POS STANDARD HMO BASIC HMO Purchases made at pharmacy (up to a 30-day supply) Level 1: Primarily generic drugs on Health Net s Recommended Drug List $5 $5 $5 Level 2: Primarily brand name drugs on Health Net s Recommended Drug List $25 $25 $25 Level 3: Covered drugs not on Health Net s Recommended Drug List $50 $50 $50 Prescriptions by Mail Program (up to a 90-day supply) Level 1 $10 $10 $10 Level 2 $40 $40 $40 Level 3 $75 $75 $75 1Certain medications are limited or excluded from coverage. Call our Customer Contact Center or review your Evidence of Coverage (which you will receive once you enroll) for a complete listing of pharmacy exclusions and limitations. 16 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES WHAT DO THE THREE LEVELS MEAN? Level 1, primarily generic drugs on the Recommended Drug List, has the lowest copay. When a generic is available, it s your best choice. Generics are equal to brand name drugs in every way: active ingredients, dosage, quality and FDA approval. The difference is, you pay less. Level 2, primarily brand name drugs on the Recommended Drug List, has a higher copayment. Your pharmacist will fill all your prescriptions with a generic if one is available, unless you or your doctor specifically asks for the brand name version. If you specifically request a brand name drug when a generic is available, you will pay the generic name copayment, plus the difference in cost between the generic drug and the brand name drug. However, if your doctor requests a brand name drug when a generic is available by hand writing, on the prescription drug order, dispense as written or do not substitute, you will only have to pay the regular Level 2 copayment. Level 3 is for covered medications not on the Recommended Drug List. Often there is an equivalent drug in Level 1 or 2, which means that another drug with the same effectiveness is available at a lower cost. Some drugs require prior authorization. PK TIP Work with your doctor to keep the cost of your prescriptions down! 1. Always ask for the generic equivalent. 2. Make sure your prescription is on the Recommended Drug List. If not, ask your doctor if there is a drug on the Recommended Drug List that will work as well as the one your doctor has prescribed. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 17
How do I get and fill prescriptions? First, get your prescription from your doctor. Make sure your prescription is covered by asking the doctor. If your doctor prescribes a drug not on the Recommended Drug List, ask if there s an alternative on the List that would work for you. To fill your prescription, just take it to any pharmacy in Health Net s network. Our network includes most statewide drug chains, including Wal-Mart, Longs, Sav-on, Rite Aid, Walgreens and others. For a complete listing of Health Net s pharmacy network, call the Customer Contact Center. 18 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES How does the mail order program work? You can save money through Health Net s prescription mail order program. This program is for medications for chronic conditions or maintenance, drugs you need to take over an extended period. With the mail order program: You will receive up to a 90-day supply of medication by mail. Your mail order copayment saves you money over three 30-day prescriptions from your local pharmacy. HOW DO I USE THE MAIL-ORDER PRESCRIPTION PROGRAM? 1. Ask your doctor for a prescription for a 90-day supply of medication, and a 30-day supply. Fill the 30-day prescription right away, and use the 90-day prescription for the mail order application. 2. Examine the prescription for the proper dosage, as well as the doctor s signature, state license number and DEA number. 3. Complete the order form. 4. Use the preaddressed, postage-paid envelope to mail the completed order forms, original prescriptions and your copayments. 5. Prescriptions will be delivered postage-paid; most by first-class mail directly to your home. Please allow 14 days from the day you mail your order. Mail order forms are available on the Internet at www.healthnet.com/homedepot. Log on and go to Get Things Done > Get Forms > Forms (claims, pharmacy and more). PK TIP You can save money with the prescription drug mail order program because it allows Health Net to negotiate better discounts and eliminate the extra cost retailers charge for overhead. The savings are passed on to you when you use the mail order program because you can order a 90-day supply of maintenance medication for one copay. Example: Level II primarily brand medication taken daily Retail (30-day supply): $25 x 12 = $300 Prescriptions by Mail (90-day supply): $40 x 4 = $160 You would save $140 and would eliminate monthly trips to the pharmacy. Plus you can order refills 24 hours a day, seven days a week. Your medications typically will arrive within 14 days. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 19
WHAT IS HEALTH NET S RECOMMENDED DRUG LIST? The Recommended Drug List is a comprehensive list of drugs covered under Tier 1 and Tier 2 of the pharmacy plan. It was developed to identify the safest and most effective medications to treat patients. The List is developed and updated by the Health Net s Pharmacy and Therapeutics (P&T) Committee, which consists of actively practicing physicians and clinical pharmacists. The Recommended Drug List is updated regularly to keep pace with current medical information. The Recommended Drug List exists for your safety, to ensure that these drugs are the most effective in their class and of high consumer value. When your physician prescribes medications on the Recommended Drug List, it ensures that you are receiving a high quality prescription medication that is also of high value. To obtain a copy of Health Net s most current Recommended Drug List, please log on to www.healthnet.com/homedepot and click on View Prescription Coverage > Your Drug List, or call the Customer Contact Center. WHO DECIDES WHAT IS ON IT? The Pharmacy and Therapeutics Committee, composed of actively practicing physicians and pharmacists, decides what is on the list. Decisions are based on clinical and safety assessments. HOW DO I KNOW IF A DRUG IS ON THE RECOMMENDED DRUG LIST? It is a good idea to find this out before you visit your pharmacy. Here are three ways: Ask your doctor. Call the Customer Contact Center. Visit www.healthnet.com/homedepot. Log on and go to View Prescription Coverage > Your Pharmacy Benefits > Your Drug List for a preferred drug on our Recommended Drug List. 20 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES WHAT IS A BRAND NAME DRUG? A drug that is still under patent. The patent allows the manufacturer the rights to name, produce and sell the product exclusively for up to 20 years. WHAT IS A GENERIC DRUG? A drug whose patent has expired may be marketed under its generic name. These are called generic drugs. Generic drugs contain the same medicine as the original brand name medication and are equivalent to the brand name. Generic drugs must meet the same FDA requirements as the brand name. Generic drugs are as equally safe and effective as their brand name counterparts. WHY DO BRAND NAME DRUGS COST MORE THAN GENERIC DRUGS? Manufacturers of brand name drugs spend a lot of money on research and advertising. While the drug is under a patent, manufacturers charge a higher cost to recoup their expenses for research and advertising. AREN T BRAND NAME DRUGS BETTER THAN GENERICS? Actually, they re the same in quality. The difference is, generics cost you less! Generic medications contain the same medicine as the original brand name and must meet the same FDA manufacturing requirements. Generic drugs are equally safe and as effective as brand name drugs for treating the same medical conditions. Generic drugs offer the same therapeutic outcomes as brand name drugs. When you want the best value for your dollar, ask your physician to prescribe generic medications. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 21
WHAT IS A PRIOR AUTHORIZATION (PA) DRUG? Certain covered drugs require prior authorization. This means that your doctor must have Health Net s pharmacy specialists review the Rx order and approve it before it can be filled. The prior authorization process guarantees you are receiving the correct medication and dosage to protect your safety and help you heal. WHY DO SOME DRUGS REQUIRE PRIOR AUTHORIZATION? Clinical or safety concerns. Laboratory or safety monitoring is needed. There is evidence that the drug could be used for experimental or off-label use. There is a potential for misuse. Quantity or duration limits are necessary. Step-care protocol is necessary (other drugs need to be tried first). HOW DO I KNOW IF A DRUG REQUIRES PRIOR AUTHORIZATION? It is a good idea to find this out before you visit your pharmacy. Here are three ways: Ask your doctor. Call the Customer Contact Center. Visit www.healthnet.com/homedepot. Log on and go to View Prescription Coverage > Your Drug List > Prior Authorization. PK TIP Prior authorization gives you the added security of knowing your medical needs are being reviewed by pharmacy professionals. 22 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ALL ASSOCIATES Questions to ask your doctor or pharmacist WHAT ARE THE IMPORTANT QUESTIONS TO ASK MY PHYSICIAN OR PHARMACIST WHEN I M PRESCRIBED A NEW MEDICATION? Here are some important things to know before you start any medication. You may want to jot down some of these questions on a notepad along with any other questions you have for your doctor. What is the name of the medication? Are there any generic equivalents available? Why am I taking this medication? Is the medication truly necessary for my condition? How, when and for how long is the medicine to be taken? What are the common side effects and how can I minimize or avoid them? What are some of the possible drug, food or lab interactions? Are there any special storage requirements? What happens when I run out of the medicine? What happens if I miss a dose? What are some of the important dietary, exercise or other lifestyle changes that should be incorporated into my daily schedule? PK TIP Sometimes answers raise new questions. Be sure to ask your doctor how you can ask additional questions that might come up between visits. Also, ask your doctor if anyone else is available to answer them. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 23
If your physician group should close ENSURING YOUR ACCESS TO CARE It s unsettling, but it s true. In any given year contracted physician groups will close down or leave the Health Net network. This is a regrettable but unavoidable part of the health care world today. HERE S WHAT HEALTH NET WILL DO TO PROTECT YOU: Health Net has years of experience in handling situations such as these. We pride ourselves on putting our members care and concerns first. Be assured that if this should happen to you, you will continue to have medical coverage. You will continue to have the ability to seek medical attention. In many cases members retain their same primary care physician by switching to another physician group where the doctor has an affiliation. In these cases, your available specialists and hospitals may change. If you are currently receiving care (specialist care, hospitalization, pregnancy or treatment for a short- or long-term condition) when the group closes or leaves the network, have your doctor contact Health Net Provider Services so we may communicate the name of the newly assigned physician group that will coordinate your care. Additionally, call Member Services for a Transition of Care form so that we may help provide any care that is appropriate for your personal circumstances. Above all, don t worry. Health Net values you and your needs. If you are contacted by your doctor, or read about a situation in the newspaper that you believe affects you, please call the Customer Contact Center. We will provide guidance and assist you in staying with your same doctor or, if necessary, finding another one near you. We re on your side, and we re committed to seeing you through any period of uncertainty. 24 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING HMO COVERAGE For associates choosing HMO coverage Use this handy chart to view your major benefits and your costs to access them. Benefits HMO STANDARD HMO BASIC What you pay for services Deductibles None None Out-of-pocket maximum One member: $2,000 One member: $2,000 Two members Two members or more: $4,000 or more: $4,000 Prescriptions Retail Mail order Retail Mail order 30-day 90-day 30-day 90-day Level I, primarily generic $5 $10 $5 $10 drugs on Health Net s Recommended Drug List (RDL) Level II, primarily brand $25 $40 $25 $40 name drugs on the RDL Level III, drugs not on $50 $75 $50 $75 the RDL Maternity care Pre-, postnatal office visits $15 per visit $25 per visit Delivery / newborn care No charge No charge Hospitalization $250 /day $350 /day (including hospitalization for first four days; for first four days; for maternity) annual max. of $1,000 annual max. of $1,400 Visit to physician $15 (Primary physician visit) $25 or specialist $25 (Specialist physician visit, including OB/Gyn self-referral) Office procedures No charge No charge (X-ray, lab work, etc.) Vision or hearing exam $15 (Primary physician visit) $25 Immunizations No charge No charge Emergency room services $100 $100 Urgent care $35 $75 center services Refer to your Evidence of Coverage (which you will receive once you enroll) for complete benefits information. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 25
How do I receive care with my HMO membership? You choose a contracted primary care physician to coordinate all your care. This doctor will work with you and Health Net for specialist referrals or hospital admissions when necessary. Your primary care physician is part of a Participating Physician Group (PPG). When you choose your primary care physician, ask about the availability of specialists and at which hospitals the doctor can admit you. These change based on the doctor and the physician group. You can choose a different primary care physician and physician group for each family member; for instance, a pediatrician for your children and a general practitioner for you. PK TIP You, your doctor, your physician group and Health Net together we all partner to serve your health care needs. Be an active participant in your care! 26 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING HMO COVERAGE How do I build a positive relationship with my primary care physician and the doctor s office staff? Developing a good relationship with your doctor is the most important thing you can do. Visit your primary care physician before you are ill. When you visit your primary care physician for the first time, discuss your medical history so your doctor can make the most informed medical decisions in your care. You may want to jot some notes down on paper so you don t forget anything important during your office visit. Plan ahead for preventive checkups. Since these visits are not urgent, they usually take longer to schedule. Of course, if you have an urgent need, your doctor will make every attempt to see you right away. If you have any problems scheduling an appointment, or if you feel you have waited too long for an appointment, call Health Net s Customer Contact Center for assistance. To help your doctor s staff serve you better, be sure to carry your Health Net ID card and identify yourself as a Health Net member. At the doctor s office, simply present your ID card and pay the appropriate copayment to obtain services from your physician. Remember, always contact your primary care physician before seeing a specialist. This way, you and your doctor can be partners in your care! PK TIP Your doctor s front office staff is a key link in the health care service chain. Get to know your doctor s staff members, by phone and in person. Let them know you are a new Health Net member. Let them get to know you, and your doctor appointments will go more smoothly. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 27
Why do I have to see my primary care physician? Your primary care physician is your prime source for medical decisions. He or she knows your medical history better than any other practitioner and is most familiar with your medical needs. If you need specialist services, your doctor is in the best position to refer you to a specialist as he or she knows the background of your medical condition best. In addition, primary care physicians have resources within their physician group and in Health Net to assure quality decision-making. These professional peers will collaborate with your doctor to ensure the best outcome and the most appropriate course of action. DOES EVERYONE IN MY FAMILY HAVE TO CHOOSE A PRIMARY CARE PHYSICIAN? Yes. Everyone must choose a primary care physician. Your primary care physician must coordinate all of your care and referrals to specialists for you to receive benefits. DOES EVERYONE IN MY FAMILY HAVE TO CHOOSE THE SAME PRIMARY CARE PHYSICIAN? No. Each covered family member must choose a primary care physician, but family members can each choose a different primary care physician. WHAT HAPPENS IF I DO NOT CHOOSE A PRIMARY CARE PHYSICIAN? If you do not select a primary care physician, a primary care physician will automatically be assigned to you. This ensures there is no delay in sending you an ID card. 28 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING HMO COVERAGE CAN I CHANGE MY PRIMARY CARE PHYSICIAN? Yes! You can change your primary care physician as often as once per month. If you ever decide to change your doctor and/or physician group, just call Health Net s Customer Contact Center. With a few exceptions, a physician or group change can be made quickly by phone or online at www.healthnet.com/homedepot. Make the change online or call the Customer Contact Center by the 15th of the month for the change to be effective the first of the following month. If you call on the 16th or after, the change will be effective the first of the month thereafter. For example, if you call May 12, your change will be effective June 1. If you call May 18, your change will be effective July 1. Call 1-800-847-3991 for more information. HOW DO I GET TO SEE A SPECIALIST? Your primary care physician works with you and Health Net to coordinate your referrals to specialists in his or her physician group. IS THERE A WAY TO SEE A SPECIALIST WITHOUT A REFERRAL FROM MY PRIMARY DOCTOR? These specialist visits do not require a referral: OB/GYN visits for women ask your doctor or Health Net for a list of OB/GYNs in the same physician group as your primary care physician. Mental health and behavioral (substance abuse) treatment visits. Call MHN, which provides these services for Health Net, at 1-800-363-9371 before you make an appointment. Chiropractic visits under your medical benefit call Health Net s Customer Contact Center for assistance in choosing a network chiropractor. PK TIP Even when going to see a specialist for care, it s a good idea to talk to your primary care physician about the visit. He or she may have some valuable medical advice to offer you, even though you re receiving care from another practitioner. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 29
What if I get a bill or a statement? First, don t worry. As an HMO member, this will rarely, if ever, happen. But if it does, here s what to do: 1. Call the office of the doctor or other health care provider that issued the statement. Find out if the statement is actually a bill, or another kind of statement. 2. If it is a bill, was it sent by accident? Health Net HMO members statements should not be sent to individual Health Net members. 3. Make sure the doctor s office has your current ID card on hand. 4. If the provider who issued the statement tells you that the statement is accurate and was sent to you for payment, call the Health Net Customer Contact Center right away. We will examine the charges and work with your doctor to correct any billing errors. 5. If you are still not satisfied with the outcome, there are more options available to you. Call the Customer Contact Center and ask for assistance in filing an appeal for the charges. We will be glad to assist you. PK TIP If your doctor ever says you owe more than your copayment because of a billing problem, call the Customer Contact Center for help immediately. We will want to talk directly to the physician in a situation like this. 30 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING HMO COVERAGE Maternity pregnancy and childbirth coverage WE RE GOING TO HAVE A BABY! WHAT IS MY FAMILY S COVERAGE? Health Net is as invested in you and your family s health as you are. Health Net s medical benefits are designed to give you peace of mind and promote a healthy delivery. We are proud to offer a comprehensive approach to pregnancy and childbirth: Free, members-only programs for expectant mothers (and fathers!) sponsored by our Wellness department offering a free gift for completing the program. For more information on this program, log on to www.healthnet.com/homedepot > It s Your Life-Wellsite > Pregnancy. Your out-of-pocket medical expenses during pregnancy and the birth of your baby are for office visits, delivery and hospitalization. For most other costs, such as genetic testing and office procedures, the plan pays 100 percent. For full information on all aspects of maternity: Talk to your doctor, Call the Customer Contact Center, or Review your Evidence of Coverage (which you will receive once you enroll). The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 31
Emergency and urgent care WHAT IF I HAVE AN EMERGENCY? AM I COVERED IF I M AWAY FROM HOME? Health Net covers emergency and urgently needed care throughout the world. If you are injured, feel severe pain, begin active labor or experience an unexpected illness that a reasonable person with an average knowledge of health and medicine would believe requires immediate treatment to prevent serious threat to your health, seek care where it is immediately available. Depending on your circumstances, you may seek emergency care by calling your physician group, going to the nearest emergency facility, or calling 911 (in areas where the system is established and operating). All ambulance services provided as a result of a 911 call will be covered, if the request is made for an emergency medical condition. All follow-up care after the urgency has passed and your condition is stable must be provided or coordinated by your primary care physician and physician group. If you go to an emergency facility for a condition that is not of an urgent or emergency nature, your out-of-pocket expenses will be higher. PK TIP If you are planning a trip out of town, call the Customer Contact Center and ask for a Travel Kit. This packet contains claim forms and other handy materials you may need if you must receive medical services while away from home. 32 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING POS COVERAGE Your SELECT POS benefits at a glance SELECT POS: THE THREE-TIER SYSTEM Use this handy chart to view your major benefits and your costs to access them. SELECT POS Benefits What you pay for services SELECT 1 SELECT 2 SELECT 3 HMO PPO Out-of-network Deductibles None $450 per member $850 per member up to $1,350 up to $2,550 maximum per maximum per family per family per calendar year calendar year (other deductibles (other deductibles may also apply) may also apply) Out-of-pocket One member: One member: One member: maximum $2,000 $2,500 $5,350 Two members Two members Two members or more: $4,000 or more: $5,000 or more: $10,700 Prescriptions Retail Mail order Retail Mail order Retail Mail order 30-day 90-day 30-day 90-day 30-day 90-day Level I, primarily $5 $10 $5 $10 $5 $10 generic drugs on Health Net s Recommended Drug List (RDL) Level II, primarily $25 $40 $25 $40 $25 $40 brand name drugs on the RDL Level III, drugs $50 $75 $50 $75 $50 $75 not on the RDL Maternity care Pre- & postnatal visits $15 per visit 20% 50% Delivery and 20% 20% 50% newborn care Refer to your Evidence of Coverage (which you will receive once you enroll) for complete benefits information. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 33
SELECT POS BENEFITS AT A GLANCE (CONTINUED) Use this handy chart to view your major benefits and your costs to access them. Benefits SELECT POS What you pay for services SELECT 1 SELECT 2 SELECT 3 HMO PPO Out-of-network Hospitalization 20% $300 plus 20% $500 plus 50% (including hospitalization for maternity) Visit to physician $15 $20 50% or specialist no deductible Office procedures No charge No charge 50% (X-ray, lab work, etc.) no deductible Vision or $15 Not covered Not covered hearing exam Immunizations $15 $20 Not covered no deductible Emergency $100 $100 plus 20% $100 plus 50% room services Urgent care $35 20% 50% center services Refer to your Evidence of Coverage (which you will receive once you enroll) for complete benefits information. 34 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING POS COVERAGE FLEXIBILITY AND OPTIONS YOU VE GOT IT ALL Health Net s SELECT POS (Point of Service) combines three types of coverage into one health plan. The services covered and amount you must pay will depend upon which option you choose each time you need health care. These three coverage types are organized in benefit tiers. SELECT 1, the HMO tier: You choose a primary care physician from Health Net s contracted HMO network. With SELECT 1, Your primary care physician coordinates all your care. This is the most economical tier for members, as there is no deductible and members generally pay set copayments for services received under this tier. SELECT 2, the PPO tier: You have the option to visit any doctor on Health Net s list of contracted PPO physicians (other than your SELECT 1 primary care physician). There is a higher cost for this tier, as members are responsible for a deductible and copayments or coinsurance for services under this tier. Certain services, such as a physician office visit, are covered without meeting the deductible. SELECT 3, the out-of-network option: You can receive care from any licensed physician not contracted with Health Net. To receive care under this tier, there is a higher deductible and higher coinsurance amounts. Certain services, such as preventive care, are not covered under this tier. PK TIP Whether you plan on using SELECT 2 or SELECT 3, you must still choose a SELECT 1 primary care physician, in case you ever want to access care under SELECT 1. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 35
HOW DO I RECEIVE CARE WITH SELECT POS? The SELECT POS plan offers three ways to receive medical care at any time. You have access to all three ways at all times. This is what Point of Service, or POS, means: As a SELECT POS member, you select the tier of care at the point of receiving service. With SELECT 1: You choose a primary care physician at the time of enrollment to be your SELECT 1 doctor. You can choose a different SELECT 1 doctor and participating physician group for each member of your family; for instance, a pediatrician for your children and a general practitioner for you. For the lowest out-of-pocket expenses, you can choose to see your SELECT 1 doctor for all care, including specialist referrals and hospital admissions. With SELECT 2 and 3: You may choose to see any doctor, in the Health Net PPO network (for SELECT 2), or outside the network (for SELECT 3). Your out-of-pocket expenses will vary based on which tier you choose. DOES EVERYONE IN MY FAMILY HAVE TO CHOOSE A PRIMARY CARE PHYSICIAN? Yes. Everyone must choose a primary care physician. Here s why: If you or a family member wants to receive SELECT 1 ( HMO ) benefits, your primary care physician must coordinate all of your care and referrals to specialists for you to receive benefits. If you use SELECT 2 ( PPO ) or SELECT 3 (out-of-network) benefits, you do not have to see your primary care physician before receiving care. However, your level of benefit will depend on whether you use a physician within the Health Net network or use an Out-of-Network provider. DOES EVERYONE IN MY FAMILY HAVE TO CHOOSE THE SAME PRIMARY CARE PHYSICIAN? No matter which level of medical benefits they access, each covered family member must choose a primary care physician. However, family members can each choose a different primary care physician. 36 The Home Depot / Health Net dedicated Customer Contact Center: 1-800-847-3991
FOR ASSOCIATES CHOOSING POS COVERAGE WHAT HAPPENS IF I DO NOT CHOOSE A PRIMARY CARE PHYSICIAN? If you do not select a primary care physician, a primary care physician will automatically be assigned to you. This ensures there is no delay in sending you an ID card. WHAT IS PRECERTIFICATION, AND WHY IS IT NECESSARY? Health Net s process for precertification of certain medical procedures under the SELECT 2 and 3 tiers (sometimes called preauthorization) helps us maintain quality medical management standards. Certain proposed services may need to be checked before approval to ensure your safety. We check medical need, appropriateness of setting and timeliness. Special criteria are used to evaluate that the procedure is medically necessary and planned for the right setting, such as inpatient or outpatient. For pre-certification, please call 1-800-977-7282. For more information on this topic, see What is precertification? in the Glossary. PK TIP Although you never have to get a referral to see a specialist, there are some good reasons you may want to: If you make your SELECT 1 primary care physician your primary doctor, he or she will always have your full medical records and history on hand, and can work with you to help you get the best and most appropriate care for your condition. If you go through your primary care physician for a specialist referral, your out-of-pocket expenses will be lower than seeing a practitioner in SELECT 2 or SELECT 3. The Home Depot / Health Net dedicated website: www.healthnet.com/homedepot 37