2014 summary benefits

2014 Summary ofBenefits

Health Net Ruby (HMO)

Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill Counties,OR

Benefits effective January 1, 2014H6815 Health Net Health Plan of Oregon, Inc.Material ID # H6815_2014_0218 CMS Accepted 09152013

SECTION I

INTRODUCTION TO

SUMMARY OF BENEFITSThank you for your interest in Health Net Ruby (HMO). Our

plan is offered by HEALTH NET HEALTH PLAN OF OREGON,

INC. which is also called Health Net Health Plan of Oregon,

Inc., a Medicare Advantage Health Maintenance Organization

(HMO) that contracts with the Federal government. This

Summary of Benefits tells you some features of our plan. It

doesn't list every service that we cover or list every limitation

or exclusion. To get a complete list of our benefits, please call

Health Net Ruby (HMO) and ask for the "Evidence of

Coverage."

YOU HAVE CHOICES INYOUR HEALTH CAREAs a Medicare beneficiary, you canchoose from different Medicareoptions. One option is the Original(Fee-for-Service) Medicare Plan.Another option is a Medicare healthplan, like Health Net Ruby (HMO).You may have other options too. Youmake the choice. No matter what youdecide, you are still in the MedicareProgram.

You may join or leave a plan only atcertain times. Please call Health NetRuby (HMO) at the telephone numberlisted at the end of this introduction or1-800-MEDICARE (1-800-633-4227)for more information. TTY/TDD users

should call 1-877-486-2048. You cancall this number 24 hours a day, 7 daysa week.

HOW CAN I COMPARE MYOPTIONS?You can compare Health Net Ruby(HMO) and the Original Medicare Planusing this Summary of Benefits. Thecharts in this booklet list someimportant health benefits. For eachbenefit, you can see what our plancovers and what the Original MedicarePlan covers.

Our members receive all of the benefitsthat the Original Medicare Plan offers.We also offer more benefits, which maychange from year to year.

WHERE IS HEALTH NETRUBY (HMO) AVAILABLE?The service area for this planincludes: Benton, Clackamas, Lane,Linn, Marion, Multnomah, Polk,Washington, Yamhill Counties, OR.You must live in one of these areas tojoin the plan.

WHO IS ELIGIBLE TO JOINHEALTH NET RUBY (HMO)?You can join Health Net Ruby (HMO)if you are entitled to Medicare Part Aand enrolled in Medicare Part B andlive in the service area. However,individuals with End-Stage RenalDisease generally are not eligible toenroll in Health Net Ruby (HMO)unless they are members of ourorganization and have been since theirdialysis began.

CAN I CHOOSE MYDOCTORS?Health Net Ruby (HMO) has formeda network of doctors, specialists, andhospitals. You can only use doctorswho are part of our network. Thehealth providers in our network canchange at any time.

You can ask for a current providerdirectory. For an updated list, visit usat https://www.healthnet.com/medicare. Our customer servicenumber is listed at the end of thisintroduction.

WHAT HAPPENS IF I GO TOA DOCTOR WHO'S NOT INYOUR NETWORK?If you choose to go to a doctor outsideof our network, you must pay for theseservices yourself. Neither the plan northe Original Medicare Plan will pay forthese services except in limitedsituations (for example, emergencycare).

WHERE CAN I GET MYPRESCRIPTIONS IF I JOINTHIS PLAN?Health Net Ruby (HMO) has formeda network of pharmacies. You must usea network pharmacy to receive planbenefits. We may not pay for yourprescriptions if you use anout-of-network pharmacy, except incertain cases. The pharmacies in ournetwork can change at any time. Youcan ask for a pharmacy directory orvisit us at https://www.healthnet.com/medicare/pharmacy. Our customerservice number is listed at the end ofthis introduction.

Health Net Ruby (HMO) has a list ofpreferred pharmacies. At thesepharmacies, you may get your drugs ata lower co-pay or co-insurance. Youmay go to a non-preferred pharmacy,but you may have to pay more for yourprescription drugs.

WHAT IF MY DOCTORPRESCRIBES LESS THAN AMONTH'S SUPPLY?In consultation with your doctor orpharmacist, you may receive less than

a month's supply of certain drugs. Also,if you live in a long-term care facility,you will receive less than a month'ssupply of certain brand drugs.Dispensing fewer drugs at a time canhelp reduce cost and waste in theMedicare Part D program, when this ismedically appropriate.

The amount you pay in thesecircumstances will depend on whetheryou are responsible for payingcoinsurance (a percentage of the costof the drug) or a copay (a flat dollaramount for the drug). If you areresponsible for coinsurance for thedrug, you will continue to pay theapplicable percentage of the drug cost.If you are responsible for a copay forthe drug, a "daily cost-sharing rate" willbe applied. If your doctor decides tocontinue the drug after a trial period,you should not pay more for a month'ssupply than you otherwise would havepaid. Contact your plan if you havequestions about cost-sharing when lessthan a one-month supply is dispensed.

DOES MY PLAN COVERMEDICARE PART B ORPART D DRUGS?Health Net Ruby (HMO) does coverboth Medicare Part B prescriptiondrugs and Medicare Part D prescriptiondrugs.

WHAT IS A PRESCRIPTIONDRUG FORMULARY?Health Net Ruby (HMO) uses aformulary. A formulary is a list of drugscovered by your plan to meet patientneeds. We may periodically add,remove, or make changes to coverage

limitations on certain drugs or changehow much you pay for a drug. If wemake any formulary change that limitsour members' ability to fill theirprescriptions, we will notify the affectedmembers before the change is made.We will send a formulary to you andyou can see our complete formulary onour Web site athttps://www.healthnet.com/medicare/pharmacy.

If you are currently taking a drug thatis not on our formulary or subject toadditional requirements or limits, youmay be able to get a temporary supplyof the drug. You can contact us torequest an exception or switch to analternative drug listed on our formularywith your physician's help. Call us tosee if you can get a temporary supplyof the drug or for more details aboutour drug transition policy.

HOW CAN I GET EXTRAHELP WITH MYPRESCRIPTION DRUG PLANCOSTS OR GET EXTRA HELPWITH OTHER MEDICARECOSTS?You may be able to get extra help topay for your prescription drugpremiums and costs as well as get helpwith other Medicare costs. To see if youqualify for getting extra help, call:

* 1-800-MEDICARE (1-800-633-4227).TTY/TDD users should call1-877-486-2048, 24 hours a day/7 daysa week;and see http://www.medicare.gov'Programs for People with Limited

Income and Resources' in thepublication Medicare & You.

* The Social Security Administrationat 1-800-772-1213 between 7 a.m. and7 p.m., Monday through Friday.TTY/TDD users should call1-800-325-0778; or

* Your State Medicaid Office.

WHAT ARE MYPROTECTIONS IN THISPLAN?All Medicare Advantage Plans agree tostay in the program for a full calendaryear at a time. Plan benefits andcost-sharing may change from calendaryear to calendar year. Each year, planscan decide whether to continue toparticipate with Medicare Advantage.A plan may continue in their entireservice area (geographic area where theplan accepts members) or choose tocontinue only in certain areas. Also,Medicare may decide to end a contractwith a plan. Even if your MedicareAdvantage Plan leaves the program,you will not lose Medicare coverage. Ifa plan decides not to continue for anadditional calendar year, it must sendyou a letter at least 90 days before yourcoverage will end. The letter willexplain your options for Medicarecoverage in your area.

As a member of Health Net Ruby(HMO), you have the right to requestan organization determination, whichincludes the right to file an appeal if wedeny coverage for an item or service,and the right to file a grievance. You

have the right to request anorganization determination if you wantus to provide or pay for an item orservice that you believe should becovered. If we deny coverage for yourrequested item or service, you have theright to appeal and ask us to review ourdecision. You may ask us for anexpedited (fast) coverage determinationor appeal if you believe that waiting fora decision could seriously put your lifeor health at risk, or affect your abilityto regain maximum function. If yourdoctor makes or supports the expeditedrequest, we must expedite our decision.Finally, you have the right to file agrievance with us if you have any typeof problem with us or one of ournetwork providers that does not involvecoverage for an item or service. If yourproblem involves quality of care, youalso have the right to file a grievancewith the Quality ImprovementOrganization (QIO) for your state.Please refer to the Evidence of Coverage(EOC) for the QIO contactinformation.

As a member of Health Net Ruby(HMO), you have the right to requesta coverage determination, whichincludes the right to request anexception, the right to file an appeal ifwe deny coverage for a prescriptiondrug, and the right to file a grievance.You have the right to request acoverage determination if you want usto cover a Part D drug that you believeshould be covered. An exception is atype of coverage determination. Youmay ask us for an exception if youbelieve you need a drug that is not onour list of covered drugs or believe you

should get a non-preferred drug at alower out-of-pocket cost. You can alsoask for an exception to cost utilizationrules, such as a limit on the quantity ofa drug. If you think you need anexception, you should contact us beforeyou try to fill your prescription at apharmacy. Your doctor must providea statement to support your exceptionrequest. If we deny coverage for yourprescription drug(s), you have the rightto appeal and ask us to review ourdecision. Finally, you have the right tofile a grievance if you have any type ofproblem with us or one of our networkpharmacies that does not involvecoverage for a prescription drug. Ifyour problem involves quality of care,you also have the right to file agrievance with the QualityImprovement Organization (QIO) foryour state. Please refer to the Evidenceof Coverage (EOC) for the QIO contactinformation.

WHAT IS A MEDICATIONTHERAPY MANAGEMENT(MTM) PROGRAM?A Medication Therapy Management(MTM) Program is a free service weoffer. You may be invited to participatein a program designed for your specifichealth and pharmacy needs. You maydecide not to participate but it isrecommended that you take fulladvantage of this covered service if youare selected. Contact Health Net Ruby(HMO) for more details.

WHAT TYPES OF DRUGSMAY BE COVERED UNDERMEDICARE PART B?Some outpatient prescription drugsmay be covered under Medicare PartB. These may include, but are notlimited to, the following types of drugs.Contact Health Net Ruby (HMO) formore details.

1 Some Antigens: If they are preparedby a doctor and administered by aproperly instructed person (whocould be the patient) under doctorsupervision.

1 Osteoporosis Drugs: Injectableosteoporosis drugs for somewomen.

1 Erythropoietin: By injection if youhave end-stage renal disease(permanent kidney failure requiringeither dialysis or transplantation)and need this drug to treat anemia.

1 Hemophilia Clotting Factors:Self-administered clotting factors ifyou have hemophilia.

1 Injectable Drugs: Most injectabledrugs administered incident to aphysician's service.

1 Immunosuppressive Drugs:Immunosuppressive drug therapyfor transplant patients if thetransplant took place in aMedicare-certified facility and waspaid for by Medicare or by a privateinsurance company that was theprimary payer for Medicare Part Acoverage.

1 Some Oral Cancer Drugs: If thesame drug is available in injectableform.

1 Oral Anti-Nausea Drugs: If you arepart of an anti-cancerchemotherapeutic regimen.

1 Inhalation and Infusion Drugsadministered through DurableMedical Equipment.

WHERE CAN I FINDINFORMATION ON PLANRATINGS?The Medicare program rates howwell plans perform in differentcategories (for example, detectingand preventing illness, ratings frompatients and customer service). Ifyou have access to the web, you canfind the Plan Ratings information byusing the Find health & drug plans

web tool on medicare.gov tocompare the plan ratings forMedicare plans in your area. You canalso call us directly to obtain a copyof the plan ratings for this plan. Ourcustomer service number is listedbelow.

Please call Health Net Health Plan of Oregon, Inc. for more information aboutHealth Net Ruby (HMO).

Visit us at https://www.healthnet.com/medicare or, call us:

Customer Service Hours for October 1 – February 14:Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,8:00 a.m. - 8:00 p.m., Pacific

Customer Service Hours for February 15 – September 30:Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,8:00 a.m. - 8:00 p.m., Pacific

Current members should call locally or toll-free (888)445-8913 for questions related tothe Medicare Advantage Program or Medicare Part D Prescription Drug Program. (TTY/TDD (800)929-9955)

Prospective members should call locally or toll-free (800)949-6192 for questions relatedto the Medicare Advantage Program or Medicare Part D Prescription Drug Program.(TTY/TDD (800)929-9955)

For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day,7 days a week.

Or, visit http://www.medicare.gov on the web.

This document may be available in other formats such as Braille, large print or other alternate formats.This document may be available in a non-English language. For additional information, call customerservice at the phone number listed above.

Este documento puede estar disponible en un idioma distinto al inglés. Para obtener informaciónadicional, llame a servicio al cliente al número de teléfono que aparece anteriormente.

If you have any questions about this plan's benefits or costs, please contactHealth Net Health Plan of Oregon, Inc. for details.

SECTION II

SUMMARY OF BENEFITS

Health Net Ruby (HMO)Original MedicareBenefit

IMPORTANT INFORMATION

General$0 monthly plan premium inaddition to your monthlyMedicare Part B premium.

In 2013 the monthly Part BPremium was $104.90 and maychange for 2014 and the annualPart B deductible amount was$147 and may change for 2014.

1. Premium and OtherImportant Information

Most people will pay thestandard monthly Part BIf a doctor or supplier does not

accept assignment, their costs premium in addition to their MAare often higher, which meansyou pay more.

plan premium. However, somepeople will pay higher Part Band Part D premiums becauseMost people will pay the

standard monthly Part B of their yearly income (over$85,000 for singles, $170,000premium. However, somefor married couples). For morepeople will pay a higherinformation about Part B andpremium because of their yearlyPart D premiums based onincome (over $85,000 for singles,income, call Medicare at$170,000 for married couples).1-800-MEDICAREFor more information about Part(1-800-633-4227). TTY usersB premiums based on income,should call 1-877-486-2048. Youcall Medicare atmay also call Social Security at1-800-MEDICARE1-800-772-1213. TTY usersshould call 1-800-325-0778.

(1-800-633-4227). TTY usersshould call 1-877-486-2048. Youmay also call Social Security at In-Network

$2,500 out-of-pocket limit forMedicare-covered services and

1-800-772-1213. TTY usersshould call 1-800-325-0778.

select Non-MedicareSupplemental services. Contactplan for details regardingNon-Medicare Supplementalservices covered under this limit.


In-NetworkYou must go to networkdoctors, specialists, andhospitals.

You may go to any doctor,specialist or hospital that acceptsMedicare.

2. Doctor and HospitalChoice(For more information, seeEmergency Care - #15 andUrgently Needed Care -#16.) No referral required for network

doctors, specialists, andhospitals.

SUMMARY OF BENEFITS

INPATIENT CARE

In-NetworkNo limit to the number of dayscovered by the plan eachhospital stay.

In 2013 the amounts for eachbenefit period were:

3. Inpatient Hospital Care(includes Substance Abuseand Rehabilitation Services)

1 Days 1 - 60: $1,184deductible

For Medicare-covered hospitalstays:

1 Days 61 - 90: $296 per day1 Days 91 - 150: $592 per

lifetime reserve day1 Days 1 - 8: $200 copay per

dayThese amounts may change for2014. 1 Days 9 - 90: $0 copay per day

Call 1-800-MEDICARE(1-800-633-4227) for informationabout lifetime reserve days.

$0 copay for each additionalnon-Medicare-covered hospitalday.

Lifetime reserve days can onlybe used once.

Except in an emergency, yourdoctor must tell the plan thatyou are going to be admitted tothe hospital.

A "benefit period" starts the dayyou go into a hospital or skillednursing facility. It ends when yougo for 60 days in a row withouthospital or skilled nursing care.If you go into the hospital afterone benefit period has ended, anew benefit period begins. Youmust pay the inpatient hospitaldeductible for each benefitperiod. There is no limit to thenumber of benefit periods youcan have.

In-NetworkYou get up to 190 days ofinpatient psychiatric hospital

In 2013 the amounts for eachbenefit period were:

4. Inpatient Mental HealthCare

1 Days 1 - 60: $1,184deductible care in a lifetime. Inpatient

psychiatric hospital services


count toward the 190-daylifetime limitation only if certain

1 Days 61 - 90: $296 per day1 Days 91 - 150: $592 per

lifetime reserve day conditions are met. Thislimitation does not apply toThese amounts may change for

2014. inpatient psychiatric servicesfurnished in a general hospital.

You get up to 190 days ofinpatient psychiatric hospital For Medicare-covered hospital

stays:care in a lifetime. Inpatient1 Days 1 - 8: $200 copay per

daypsychiatric hospital servicescount toward the 190-day

1 Days 9 - 90: $0 copay per daylifetime limitation only if certainconditions are met. This Plan covers 60 lifetime reserve

days. $0 copay per lifetimereserve day.

limitation does not apply toinpatient psychiatric servicesfurnished in a general hospital.

Except in an emergency, yourdoctor must tell the plan thatyou are going to be admitted tothe hospital.

GeneralAuthorization rules may apply.

In 2013 the amounts for eachbenefit period after at least a

5. Skilled Nursing Facility(SNF)(in a Medicare-certifiedskilled nursing facility) In-Network

Plan covers up to 100 days eachbenefit period

3-day Medicare-covered hospitalstay were:

1 Days 1 - 20: $0 per day1 Days 21 - 100: $148 per day No prior hospital stay is

required.These amounts may change for2014. For Medicare-covered SNF

stays:100 days for each benefit period.

1 Days 1 - 20: $0 copay per dayA "benefit period" starts the dayyou go into a hospital or SNF. It 1 Days 21 - 100: $100 copay

per dayends when you go for 60 days ina row without hospital or skillednursing care. If you go into thehospital after one benefit periodhas ended, a new benefit periodbegins. You must pay theinpatient hospital deductible foreach benefit period. There is nolimit to the number of benefitperiods you can have.

4. Inpatient Mental HealthCare(continued)



$0 copay.6. Home Health Care(includes medicallynecessary intermittentskilled nursing care, homehealth aide services, andrehabilitation services, etc.)

In-Network$0 copay for eachMedicare-covered home healthvisit

GeneralYou must get care from aMedicare-certified hospice. You

You pay part of the cost foroutpatient drugs and inpatientrespite care.

7. Hospice

must consult with your planbefore you select hospice.

You must get care from aMedicare-certified hospice.

OUTPATIENT CARE

In-Network$8 copay for eachMedicare-covered primary caredoctor visit.

20% coinsurance8. Doctor Office Visits

$20 copay for eachMedicare-covered specialistvisit.


Supplemental routine care notcovered

9. Chiropractic Services

In-Network$15 copay for eachMedicare-covered chiropracticvisit

20% coinsurance for manualmanipulation of the spine tocorrect subluxation (adisplacement or misalignment ofa joint or body part). $15 copay for each

supplemental routinechiropractic visit

Medicare-covered chiropracticvisits are for manualmanipulation of the spine tocorrect subluxation (adisplacement or misalignmentof a joint or body part).

In-Network$20 copay for eachMedicare-covered podiatry visit

Supplemental routine care notcovered.

20% coinsurance for medicallynecessary foot care, including

10. Podiatry Services


Medicare-covered podiatry visitsare for medically necessary footcare.

care for medical conditionsaffecting the lower limbs.


20% coinsurance for mostoutpatient mental health services

11. Outpatient Mental HealthCare

In-Network$25 copay for eachMedicare-covered individualtherapy visit

Specified copayment foroutpatient partial hospitalizationprogram services furnished by ahospital or community mentalhealth center (CMHC). Copay $25 copay for each

Medicare-covered grouptherapy visit

cannot exceed the Part Ainpatient hospital deductible.

"Partial hospitalization program"is a structured program of active

$25 copay for eachMedicare-covered individualtherapy visit with a psychiatristoutpatient psychiatric treatment

that is more intense than the$25 copay for eachMedicare-covered grouptherapy visit with a psychiatrist

care received in your doctor's ortherapist's office and is analternative to inpatienthospitalization. $0 copay for Medicare-covered

partial hospitalization programservices

In-Network$25 copay for Medicare-coveredindividual substance abuseoutpatient treatment visits

20% coinsurance12. Outpatient SubstanceAbuse Care

$25 copay for Medicare-coveredgroup substance abuseoutpatient treatment visits


20% coinsurance for the doctor'sservices

13. Outpatient Services

In-Network$150 copay for eachMedicare-covered ambulatorysurgical center visit

Specified copayment foroutpatient hospital facilityservices. Copay cannot exceedthe Part A inpatient hospitaldeductible. $175 copay for each

Medicare-covered outpatienthospital facility visit

20% coinsurance for ambulatorysurgical center facility services


20% coinsurance14. Ambulance Services(medically necessaryambulance services)

10. Podiatry Services(continued)


In-Network$295 copay forMedicare-covered ambulancebenefits.

General$65 copay for Medicare-coveredemergency room visits

20% coinsurance for the doctor'sservices

Specified copayment foroutpatient hospital facilityemergency services.

15. Emergency Care(You may go to anyemergency room if youreasonably believe youneed emergency care.) $50,000 plan coverage limit for

supplemental emergencyservices outside the U.S. and itsterritories every year.

Emergency services copaycannot exceed Part A inpatienthospital deductible for eachservice provided by the hospital.

If you are admitted to thehospital within 24-hour(s) for thesame condition, you pay $0 forthe emergency room visit.

You don't have to pay theemergency room copay if youare admitted to the hospital asan inpatient for the samecondition within 3 days of theemergency room visit.

Not covered outside the U.S.except under limitedcircumstances.

General$25 copay for Medicare-coveredurgently-needed-care visits

20% coinsurance, or a set copay

If you are admitted to thehospital within 3 days for the

16. Urgently Needed Care(This is NOT emergencycare, and in most cases, isout of the service area.)

If you are admitted to thehospital within 24-hour(s) for the

same condition, you pay $0 forthe urgently-needed-care visit.

same condition, you pay $0 forthe urgently-needed-care visit.

NOT covered outside the U.S.except under limitedcircumstances.


20% coinsurance

Medically necessary physicaltherapy, occupational therapy,

17. Outpatient RehabilitationServices(Occupational Therapy,Physical Therapy, Speechand Language Therapy)

Medically necessary physicaltherapy, occupational therapy,and speech and languagepathology services are covered.

and speech and languagepathology services are covered.

In-Network$25 copay for Medicare-coveredOccupational Therapy visits

14. Ambulance Services(medically necessaryambulance services)(continued)


$25 copay for Medicare-coveredPhysical Therapy and/or Speechand Language Pathology visits

OUTPATIENT MEDICAL SERVICES AND SUPPLIES


20% coinsurance18. Durable MedicalEquipment(includes wheelchairs,oxygen, etc.) In-Network

15% of the cost forMedicare-covered durablemedical equipment


20% coinsurance

20% coinsurance forMedicare-covered medical

19. Prosthetic Devices(includes braces, artificiallimbs and eyes, etc.)

In-Network15% of the cost forMedicare-covered prostheticdevices

supplies related to prosthetics,splints, and other devices.

15% of the cost forMedicare-covered medicalsupplies related to prosthetics,splints, and other devices

In-Network$0 copay for Medicare-coveredDiabetes self-managementtraining

20% coinsurance for diabetesself-management training

20% coinsurance for diabetessupplies

20. Diabetes Programs andSupplies

$0 copay for Medicare-coveredDiabetes monitoring supplies

20% coinsurance for diabetictherapeutic shoes or inserts

15% of the cost forMedicare-covered Therapeuticshoes or inserts

Diabetic Supplies and Servicesare limited to specificmanufacturers, products and/orbrands. Contact the plan for alist of covered supplies.

17. Outpatient RehabilitationServices(Occupational Therapy,Physical Therapy, Speechand Language Therapy)(continued)



20% coinsurance for diagnostictests and x-rays

21. Diagnostic Tests, X-Rays,Lab Services, andRadiology Services

In-Network$0 copay for Medicare-coveredlab services

$0 copay for Medicare-coveredlab services

Lab Services: Medicare coversmedically necessary diagnostic 0% to 15% of the cost for

Medicare-covered diagnosticprocedures and tests

lab services that are ordered byyour treating doctor when theyare provided by a Clinical $15 copay for Medicare-covered

X-raysLaboratory ImprovementAmendments (CLIA) certified

15% of the cost forMedicare-covered diagnostic

laboratory that participates inMedicare. Diagnostic lab services

radiology services (not includingX-rays)

are done to help your doctordiagnose or rule out a suspectedillness or condition. Medicare 15% of the cost for

Medicare-covered therapeuticradiology services

does not cover mostsupplemental routine screeningtests, like checking yourcholesterol.

In-Network$25 copay for Medicare-coveredCardiac Rehabilitation Services

20% coinsurance for CardiacRehabilitation services

20% coinsurance for PulmonaryRehabilitation services

22. Cardiac and PulmonaryRehabilitation Services

$25 copay for Medicare-coveredIntensive Cardiac RehabilitationServices

20% coinsurance for IntensiveCardiac Rehabilitation services

$25 copay for Medicare-coveredPulmonary RehabilitationServices

PREVENTIVE SERVICES

General$0 copay for all preventiveservices covered under OriginalMedicare at zero cost sharing.

No coinsurance, copayment ordeductible for the following:

23. Preventive Services

1 Abdominal Aortic AneurysmScreening

Any additional preventiveservices approved by Medicare

1 Bone Mass Measurement.Covered once every 24months (more often ifmedically necessary) if youmeet certain medicalconditions.

mid-year will be covered by theplan or by Original Medicare.

In-Network$0 copay for a supplementalannual physical exam1 Cardiovascular Screening


1 Cervical and Vaginal CancerScreening. Covered onceevery 2 years. Covered oncea year for women withMedicare at high risk.

1 Colorectal Cancer Screening1 Diabetes Screening1 Influenza Vaccine1 Hepatitis B Vaccine for

people with Medicare whoare at risk

1 HIV Screening. $0 copay forthe HIV screening, but yougenerally pay 20% of theMedicare-approved amountfor the doctor's visit. HIVscreening is covered forpeople with Medicare whoare pregnant and people atincreased risk for theinfection, including anyonewho asks for the test.Medicare covers this testonce every 12 months or upto three times during apregnancy.

1 Breast Cancer Screening(Mammogram). Medicarecovers screeningmammograms once every 12months for all women withMedicare age 40 and older.Medicare covers one baselinemammogram for womenbetween ages 35-39.

1 Medical Nutrition TherapyServices. Nutrition therapy isfor people who have diabetesor kidney disease (but aren'ton dialysis or haven't had akidney transplant) whenreferred by a doctor. Theseservices can be given by aregistered dietitian and mayinclude a nutritionalassessment and counseling tohelp you manage yourdiabetes or kidney disease

23. Preventive Services(continued)


1 Personalized Prevention PlanServices (Annual WellnessVisits)

1 Pneumococcal Vaccine. Youmay only need thePneumonia vaccine once inyour lifetime. Call your doctorfor more information.

1 Prostate Cancer Screening1 Prostate Specific Antigen

(PSA) test only. Covered oncea year for all men withMedicare over age 50.

1 Smoking and Tobacco UseCessation (counseling to stopsmoking and tobacco use).Covered if ordered by yourdoctor. Includes twocounseling attempts within a12-month period. Eachcounseling attempt includesup to four face-to-face visits.

1 Screening and behavioralcounseling interventions inprimary care to reducealcohol misuse

1 Screening for depression inadults

1 Screening for sexuallytransmitted infections (STI)and high-intensity behavioralcounseling to prevent STIs

1 Intensive behavioralcounseling for CardiovascularDisease (bi-annual)

1 Intensive behavioral therapyfor obesity



1 Welcome to MedicarePreventive Visit (initialpreventive physical exam)When you join Medicare PartB, then you are eligible asfollows. During the first 12months of your new Part Bcoverage, you can get eithera Welcome to MedicarePreventive Visit or an AnnualWellness Visit. After your first12 months, you can get oneAnnual Wellness Visit every12 months.

In-Network20% of the cost forMedicare-covered renal dialysis

20% coinsurance for renaldialysis

20% coinsurance for kidneydisease education services

24. Kidney Disease andConditions

$0 copay for Medicare-coveredkidney disease educationservices

PRESCRIPTION DRUG BENEFITS

Drugs Covered Under MedicarePart BGeneral15% of the cost for MedicarePart B chemotherapy drugs andother Part B drugs.

Most drugs are not coveredunder Original Medicare. Youcan add prescription drugcoverage to Original Medicareby joining a MedicarePrescription Drug Plan, or you

25. Outpatient PrescriptionDrugs

can get all your Medicare Drugs Covered Under MedicarePart DGeneralThis plan uses a formulary. Theplan will send you the formulary.

coverage, including prescriptiondrug coverage, by joining aMedicare Advantage Plan or aMedicare Cost Plan that offersprescription drug coverage. You can also see the formulary

at https://www.healthnet.com/medicare/pharmacy on the web.

Different out-of-pocket costsmay apply for people who

1 have limited incomes,1 live in long term care

facilities, or1 have access to Indian/Tribal/

Urban (Indian Health Service)providers.



The plan offers nationalin-network prescriptioncoverage (i.e., this would include50 states and the District ofColumbia). This means that youwill pay the same cost-sharingamount for your prescriptiondrugs if you get them at anin-network pharmacy outside ofthe plan's service area (forinstance when you travel).

Total yearly drug costs are thetotal drug costs paid by bothyou and a Part D plan.

The plan may require you to firsttry one drug to treat yourcondition before it will coveranother drug for that condition.

Some drugs have quantity limits.

Your provider must get priorauthorization from Health NetRuby (HMO) for certain drugs.

You must go to certainpharmacies for a very limitednumber of drugs, due to specialhandling, provider coordination,or patient educationrequirements that cannot bemet by most pharmacies in yournetwork. These drugs are listedon the plan's website, formulary,printed materials, as well as onthe Medicare Prescription DrugPlan Finder on Medicare.gov.

If the actual cost of a drug is lessthan the normal cost-sharingamount for that drug, you willpay the actual cost, not thehigher cost-sharing amount.

If you request a formularyexception for a drug and HealthNet Ruby (HMO) approves theexception, you will pay Tier 4:

25. Outpatient PrescriptionDrugs(continued)


Non-Preferred Brand costsharing for that drug.

In-Network$0 deductible.

Initial CoverageYou pay the following until totalyearly drug costs reach $2,850:

Retail PharmacyContact your plan if you havequestions about cost-sharing orbilling when less than aone-month supply is dispensed.

You can get drugs the followingway(s):

Tier 1: Preferred Generic

1 $4 copay for a one-month(30-day) supply of drugs inthis tier

1 $8 copay for a two-month(60-day) supply of drugs inthis tier

1 $12 copay for a three-month(90-day) supply of drugs inthis tier

Tier 2: Non-Preferred Generic




Tier 3: Preferred Brand





1 $114 copay for athree-month (90-day) supplyof drugs in this tier

Tier 4: Non-Preferred Brand



1 $285 copay for athree-month (90-day) supplyof drugs in this tier

Tier 5: Specialty Tier

1 33% coinsurance for aone-month (30-day) supplyof drugs in this tier

1 33% coinsurance for atwo-month (60-day) supplyof drugs in this tier

1 33% coinsurance for athree-month (90-day) supplyof drugs in this tier

Tier 6: Select Care Drugs




Long Term Care PharmacyLong term care pharmacies mustdispense brand name drugs inamounts less than a 14 dayssupply at a time. They may alsodispense less than a month'ssupply of generic drugs at atime. Contact your plan if youhave questions aboutcost-sharing or billing when less



than a one-month supply isdispensed.

You can get drugs the followingway(s):













Mail OrderContact your plan if you havequestions about cost-sharing orbilling when less than aone-month supply is dispensed.

You can get drugs from apreferred and non-preferredmail order pharmacy thefollowing way(s):




1 $4 copay for a one-month(30-day) supply of drugs inthis tier from a preferred mailorder pharmacy.

1 $8 copay for a two-month(60-day) supply of drugs inthis tier from a preferred mailorder pharmacy.

1 $8 copay for a three-month(90-day) supply of drugs inthis tier from a preferred mailorder pharmacy.

1 $4 copay for a one-month(30-day) supply of drugs inthis tier from a non-preferredmail order pharmacy.

1 $8 copay for a two-month(60-day) supply of drugs inthis tier from a non-preferredmail order pharmacy.

1 $12 copay for a three-month(90-day) supply of drugs inthis tier from a non-preferredmail order pharmacy.
















1 $114 copay for athree-month (90-day) supplyof drugs in this tier from anon-preferred mail orderpharmacy.




1 $238 copay for athree-month (90-day) supplyof drugs in this tier from apreferred mail orderpharmacy.





1 $285 copay for athree-month (90-day) supplyof drugs in this tier from anon-preferred mail orderpharmacy.


1 33% coinsurance for aone-month (30-day) supplyof drugs in this tier from apreferred mail orderpharmacy.

1 33% coinsurance for atwo-month (60-day) supplyof drugs in this tier from apreferred mail orderpharmacy.

1 33% coinsurance for athree-month (90-day) supplyof drugs in this tier from apreferred mail orderpharmacy.

1 33% coinsurance for aone-month (30-day) supplyof drugs in this tier from anon-preferred mail orderpharmacy.

1 33% coinsurance for atwo-month (60-day) supplyof drugs in this tier from anon-preferred mail orderpharmacy.

1 33% coinsurance for athree-month (90-day) supplyof drugs in this tier from anon-preferred mail orderpharmacy.










Coverage GapAfter your total yearly drug costsreach $2,850, you receivelimited coverage by the plan oncertain drugs. You will alsoreceive a discount on brandname drugs and generally payno more than 47.5% for theplan's costs for brand drugs and72% of the plan's costs forgeneric drugs until your yearlyout-of-pocket drug costs reach$4,550.

Catastrophic CoverageAfter your yearly out-of-pocketdrug costs reach $4,550, youpay the greater of:

1 5% coinsurance, or



1 $2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.

Out-of-NetworkPlan drugs may be covered inspecial circumstances, forinstance, illness while travelingoutside of the plan's service areawhere there is no networkpharmacy. You may have to paymore than your normalcost-sharing amount if you getyour drugs at an out-of-networkpharmacy. In addition, you willlikely have to pay thepharmacy's full charge for thedrug and submit documentationto receive reimbursement fromHealth Net Ruby (HMO).

You can get out-of-networkdrugs the following way:

Out-of-Network Initial CoverageYou will be reimbursed up to theplan's cost of the drug minus thefollowing for drugs purchasedout-of-network until total yearlydrug costs reach $2,850:















Out-of-Network Coverage GapYou will be reimbursed up to28% of the plan allowable costfor generic drugs purchasedout-of-network until total yearlyout-of-pocket drug costs reach$4,550. Please note that theplan allowable cost may be lessthan the out-of-networkpharmacy price paid for yourdrug(s).

You will be reimbursed up to52.5% of the plan allowable costfor brand name drugs purchasedout-of-network until your totalyearly out-of-pocket drug costsreach $4,550. Please note thatthe plan allowable cost may beless than the out-of-networkpharmacy price paid for yourdrug(s).

Out-of-Network CatastrophicCoverageAfter your yearly out-of-pocketdrug costs reach $4,550, you willbe reimbursed for drugspurchased out-of-network up tothe plan's cost of the drug minusyour cost share, which is thegreater of:

1 5% coinsurance, or



1 $2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.

OUTPATIENT MEDICAL SERVICES AND SUPPLIES

In-NetworkThis plan covers somepreventive dental benefits for

Preventive dental services (suchas cleaning) not covered.

26. Dental Services

an extra cost (see "OptionalSupplemental Benefits.")

$20 copay for Medicare-covereddental benefits

In-NetworkIn general, supplemental routinehearing exams and hearing aidsnot covered.

Supplemental routine hearingexams and hearing aids notcovered.

20% coinsurance for diagnostichearing exams.

27. Hearing Services

$20 copay for Medicare-covereddiagnostic hearing exams

In-Network$0 to $20 copay forMedicare-covered exams to

20% coinsurance for diagnosisand treatment of diseases andconditions of the eye, including

28. Vision Services

diagnose and treat diseases andan annual glaucoma screeningfor people at risk conditions of the eye, including

an annual glaucoma screeningfor people at risk

Supplemental routine eye examsand eyeglasses (lenses andframes) not covered. $10 copay for up to 1

supplemental routine eyeexam(s) every year

Medicare pays for one pair ofeyeglasses or contact lensesafter cataract surgery. $0 copay for one pair of

Medicare-covered eyeglasses(lenses and frames) or contactlenses after cataract surgery.

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

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

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



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

$250 plan coverage limit forsupplemental eyewear every twoyears

In-NetworkThe plan covers the followingsupplemental education/wellness programs:

Not covered.Wellness/Education and OtherSupplemental Benefits &Services

1 Health Education1 Additional Smoking and

Tobacco Use Cessation Visits1 Health Club Membership/

Fitness Classes1 Nursing Hotline

GeneralThe plan does not coverOver-the-Counter items.

Not covered.Over-the-Counter Items

In-NetworkThis plan does not coversupplemental routinetransportation.

Not covered.Transportation(Routine)


Not covered.Acupuncture and OtherAlternative Therapies

In-Network$15 copay per visit foracupuncture and otheralternative therapies

OPTIONAL SUPPLEMENTAL PACKAGE #1

GeneralPackage: 1 - Preventive DentalPlus:

Premium and Other ImportantInformation

$31 monthly premium, inaddition to your $0 monthly planpremium and the monthlyMedicare Part B premium, forthe following optional benefits:

1 Preventive Dental1 Comprehensive Dental

28. Vision Services(continued)


$1,250 plan coverage limit everyyear for these benefits.

$35 deductible for thesebenefits.

GeneralPlan offers additionalsupplemental comprehensivedental benefits.

Dental Services

In-Network$0 copay for up to 2supplemental oral exam(s) everyyear

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

$0 copay for up to 1supplemental dental x-ray(s)every year

$1,250 plan coverage limit forsupplemental dental benefitsevery year

Premium and Other ImportantInformation(continued)

For more information, please contact:Health Net Medicare ProgramsPO BOX 10420VAN NUYS, CA 91410-0420

Visit us at https://www.healthnet.com/medicare or, call us:Customer Service Hours for October 1 – February 14:

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific

Customer Service Hours for February 15 – September 30:

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific

Current members should call locally or toll-free (888)445-8913 for questions related to the MedicareAdvantage Program or Medicare Part D Prescription Drug Program. (TTY/TDD (800)929-9955)

Prospective members should call locally or toll-free (800)949-6192 for questions related to the MedicareAdvantage Program or Medicare Part D Prescription Drug Program. (TTY/TDD (800)929-9955)

OR99718 (9/13)Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, Inc.Health Net is a registered service mark of Health Net, Inc. All rights reserved.

2014 summary benefits

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