BENEFIT HIGHLIGHT BROCHURE
2021-2022
Excelcare EOA 10 (GZS) Narrow Network
EOA 10 (GZ2) Full Network Calendar Year Deductible
(Individual / Family) None None
Calendar Year Out-of-Pocket Maximum
(Individual / Family) $1,500 / $3,000 $1,500 / $3,000
Annual Preventative Visit No Charge No Charge
Office / Specialist Visits $10 Copay / $30 Copay $10 Copay / $30 Copay
Urgent Care $30 Copay $30 Copay
Telehealth Consultation No Charge No Charge
Diagnostic Services (Routine Lab & X-Ray) No Charge No Charge
Diagnostic Services (Complex Imaging) $100 Copay $100 Copay
Inpatient Hospitalization $250 Copay Per Admission $250 Copay Per Admission
Outpatient Surgery $250 Copay $250 Copay
Emergency Room (Waived if Admitted) $100 Copay $100 Copay
Chiropractic Services
(Up to 30 Visits Per Calendar Year) $10 Copay $10 Copay
Acupuncture Services
(Up to 30 Visits Per Calendar Year) $10 Copay $10 Copay
Prescription Drug Coverage (Rx)
Calendar Year Rx Deductible None None
Tier 1 – Generic $10 Copay $10 Copay
Tier 2 – Brand $30 Copay $30 Copay
Tier 3 – Non-formulary $50 Copay $50 Copay
Tier 4 - Specialty 30%, Maximum $250 30%, Maximum $250
Mail Order Prescriptions
(Up to a 90 Day Supply) $20 / $75 / $125 / N/A $20 / $75 / $125 / N/A
Provider Network POS - Elect Open Access ExcelCare
Small Group/Large Group
POS - Elect Open Access Small Group/Large Group
HMO
HSA 2800 (GYP) In – Network*
PPO 1000 (GYF) In – Network*
Calendar Year Deductible
(Individual / Family) $2,800 / $5,600 $1,000 / $3,000
Calendar Year Out-of-Pocket Maximum
(Individual / Family) $2,800 / $5,600 $3,000 / $9,000
Annual Preventative Visit No Charge No Charge
Office / Specialist Visits No Charge, After Deductible $30 Copay / $50 Copay
Urgent Care No Charge, After Deductible $50 Copay
Telehealth Consultation No Charge, After Deductible No Charge, After Deductible
Diagnostic Services (Routine Lab & X-Ray) No Charge, After Deductible 20% Coinsurance, After Deductible Diagnostic Services (Complex Imaging) No Charge, After Deductible 20% Coinsurance, After Deductible Inpatient Hospitalization No Charge, After Deductible 20% Coinsurance, After Deductible
Outpatient Surgery No Charge, After Deductible 20% Coinsurance, After Deductible
Emergency Room (Waived if Admitted) No Charge, After Deductible $100 Copay then 20% Coinsurance, After Deductible
Chiropractic Services $1,500 calendar year max
(Unlimited Visits) No Charge, After Deductible $30 Copay
Acupuncture Services
(Unlimited Visits) No Charge, After Deductible 20% Coinsurance, After Deductible
Prescription Drug Coverage (Rx)
Calendar Year Rx Deductible Combined with Medical Deductible None
Tier 1 – Generic No Charge, After Deductible $10 Copay
Tier 2 – Brand, preferred No Charge, After Deductible $30 Copay
Tier 3 – Non-formulary No Charge, After Deductible $50 Copay
Specialty Tier No Charge, After Deductible 30%, Maximum $250
Mail Order Prescriptions
(Up to a 90 Day Supply) No Charge, After Deductible $20 / $75 / $125 / N/A
Provider Network PPO – Large Group/Small Group PPO – Large Group/Small Group
*For “Out-of-Network” benefits please refer to the complete Benefit Summary.
PPO
DHMO DPPO In – Network*
Annual Deductible (Individual / Family) None $50 Individual / $150 Family
Annual Plan Maximum None $1,500
Diagnostic & Preventive Services
Oral Evaluation Covered 100% Covered 100%
Basic Cleanings Covered 100% Covered 100%
Basic Services
Amalgam Fillings Scheduled Copays Covered 80%
Root Canal Scheduled Copays Covered 80%
Oral Surgery Scheduled Copays Covered 80%
Major Services
Crowns Scheduled Copays Covered 50%
Dentures Scheduled Copays Covered 50%
Orthodontic Services
Orthodontia Lifetime Maximum $2,400 Not Covered
Comprehensive Orthodontic Treatment
Adult $2,400** Not Covered
Child $2,400** Not Covered
Provider Network DMO/DNO – Select Dental PPO/PDN with PPOII
Out-of-Network Reimbursement N/A 90thUCR
*For “Out-of-Network” benefits please refer to the complete Benefit Summary.
** Excludes transitional dentition
DENTAL
In – Network*
Exam (Every 12 months) $25 Copay
Lenses (Every 12 months)
Single Covered 100%
Bifocal Covered 100%
Trifocal Covered 100%
Frames (Every 12 months) Up to $130 Allowance** + 20% Discount Off Remaining Balance
Standard Contact Lenses (Every 12 months) Instead of eyeglass lenses
Up to $130 Allowance** + 15% Discount Off Remaining Balance
Standard Contact Lens Fit/Follow-Up $40 Fee
Provider Network Aetna Vision Preferred
*For “Out-of-Network” benefits please refer to the complete Benefit Summary.
** Allowances are one-time use benefits
VISION
Video Medical Appointments with a Provider 24 hours a day, 7 days a week
Available at no cost for Health Net members.
Speak to a doctor, 24/7
Receive medical advice, referrals to specialists, and get prescriptions sent to the pharmacy of your choice.
Do a Health check
Answer questions about your lifestyle and family history. Understand your current and future health, and learn how to stay healthy long-term.
Check your symptoms
Describe what’s wrong and our Chatbot can help. Use powerful artificial
intelligence to identify possible causes, and get connected with the resources you need.
Download the app . Search for Babylon in the Apple App Store or on Google Play.
--- OR --- Scan one of the QR codes to the right
1
2 Register yourself. When Babylon asks if you have a code, enter: HNCOM
3 Add a child under 18. Tap the Me tab and select Family
QUESTIONS:
Call : (( (800) 475-6168 Email: ([email protected] Web: babylonhealth.com/us/hn
Basic Life Insurance (Company Paid)
All eligible employees are covered for $30,000 for Group Term Life Insurance.
Your benefit will reduce to 65% of the original amount when you turn 65 and to 50% of the original amount when you reach 70.
Employee Assistance Program (EAP) (Company Paid)
The demands of today’s changing workplace along with daily life stressors can affect the overall quality of life. REACH EAP, is committed to assisting in improving
the quality of your life. This is achieved by helping you get the right assistance to help reduce the impact of work and personal stress, 24 hours/7 days a week.
Phone: 714-533-5767 Toll Free: 800-273-5273 Email: [email protected]
This is only a summary of benefits. For a complete listing of benefits and exclusions, please refer to the summary plan description. In the event of conflict, the contract is the final authority.
