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Health Net www. healthnet. com
2002

A Health Maintenance Organization

Serving: Most of California
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

This plan has commendable accreditation from the NCQA. See the 2002 Guide for more information on accreditation.
Enrollment codes for this Plan:
LB1 Self Only LB2 Self and Family

For changes in benefits,
see page 10

RI 73-159 1
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2002 HEALTH NET 2
Table of Contents Introduction…………………………………………………………………............................................................................................. 4
Plain Language………………………………………………………………............................................................................................ 4
Inspector General Advisory........................................................................................................................................................................ 4
Section 1. Facts about this HMO plan....................................................................................................................................................... 6
How we pay providers.............................................................................................................................................................. 6
Who provides my health care? ................................................................................................................................................. 6
Your Rights .............................................................................................................................................................................. 6
Service Area ............................................................................................................................................................................. 7
Section 2. How we change for 2002………………………………………............................................................................................ 10
Program-wide changes ........................................................................................................................................................... 10
Changes to this Plan ............................................................................................................................................................... 10
Section 3. How you get care …………................................................................................................................................................... 11
Identification cards ................................................................................................................................................................. 11
Where you get covered care ................................................................................................................................................... 11
Plan providers .................................................................................................................................................................. 11
Plan facilities.................................................................................................................................................................... 11
What you must do to get covered care ................................................................................................................................... 11
Primary care ..................................................................................................................................................................... 11
Specialty care ................................................................................................................................................................... 12
Hospital care .................................................................................................................................................................... 13
Circumstances beyond our control ......................................................................................................................................... 13
Services requiring our prior approval ..................................................................................................................................... 13
Section 4. Your costs for covered services.............................................................................................................................................. 14
Copayments...................................................................................................................................................................... 14
Deductible ........................................................................................................................................................................ 14
Coinsurance...................................................................................................................................................................... 14
Your out-of-pocket maximum................................................................................................................................................ 14
Section 5. Benefits…………………………………………………………........................................................................................... 15
Overview................................................................................................................................................................................ 15
(a) Medical services and supplies provided by physicians and other health care professionals........................................ 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 25
(c) Services provided by a hospital or other facility, and ambulance services .................................................................. 29
(d) Emergency services/ accidents ..................................................................................................................................... 32
(e) Mental health and substance abuse benefits ................................................................................................................ 34
(f) Prescription drug benefits ............................................................................................................................................ 36
(g) Special features............................................................................................................................................................ 39
Flexible benefits option

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2002 HEALTH NET 3
Services for the Deaf and hearing Impaired
24 Hour Nurse Line
Early Prenatal Program
Centers of Excellence
(h) Dental benefits ............................................................................................................................................................. 40
(i) Non-FEHB benefits available to Plan members .......................................................................................................... 41
Section 6. General exclusions --things we don't cover .......................................................................................................................... 42
Section 7. Filing a claim for covered services......................................................................................................................................... 43
Section 8. The disputed claims process ................................................................................................................................................... 44
Section 9. Coordinating benefits with other coverage............................................................................................................................. 46
When you have…
Other health coverage...................................................................................................................................................... 46
Original Medicare ........................................................................................................................................................... 46
Medicare managed care plan........................................................................................................................................... 48
TRICARE/ Workers' Compensation/ Medicaid ...................................................................................................................... 49
Other Government agencies .................................................................................................................................................. 49
When others are responsible for injuries ............................................................................................................................... 49
Section 10. Definitions of terms we use in this brochure ........................................................................................................................ 50
Section 11. FEHB facts ........................................................................................................................................................................... 51

Coverage information…. ............................................................................................................................................ ……… 51
No pre-existing condition limitation .............................................................................................................................. 51
Where you get information about enrolling in the FEHB Program................................................................................ 51
Types of coverage available for you and your family .................................................................................................... 51
When benefits and premiums start ................................................................................................................................. 51
Your medical and claims records are confidential ......................................................................................................... 51
When you retire............................................................................................................................................................. 52
When you lose benefits ........................................................................................................................................................ 52
When FEHB coverage ends ........................................................................................................................................... 52
Spouse equity coverage................................................................................................................................................. 52
Temporary Continuation of Coverage (TCC) ............................................................................................................... 52
Converting to individual coverage ................................................................................................................................ 53
Getting a Certificate of Group Health Plan Coverage ................................................................................................... 53
Long term care insurance is coming later in 2002.................................................................................................................................... 54

Department of Defense/ FEHB Demonstration Project ............................................................................................................................ 55
Index……………………………………………………………………………………………………………………………………… 57
Summary of benefits ................................................................................................................................................................................ 58
Rates……………………………………………………………………………………………………………………………. Back cover

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2002 HEALTH NET 4
Introduction
Health Net P. O. Box 9103
Van Nuys, CA 91409-9103
This brochure describes the benefits of Health Net under our contract (CS 2002) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits. No oral statement can
modify or otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on page 10. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Health Net.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm .gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E S treet, NW Washington, DC 20415-3650:

Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice
for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-800-522-0088 and explain the
situation. If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--
202/ 418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW, Room 6400,
Washington, DC 20415.

Introduction/ Plain Language/ Advisory 4
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2002 HEALTH NET 5
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the
person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you.

Introduction/ Plain Language/ Advisory 5
5 Page 6 7

2002 HEALTH NET 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
Typically, we contract with Participating Physician Groups (PPGs), rather than directly with physicians, on a capitated basis for HMO plans. We will also contract directly with an individual physician in rural areas where PPGs do not exist.

In contractual agreements with PPGs that are capitated, we prepay PPGs a monthly fixed dollar amount based on a Per Member Per Month (PMPM) rate schedule. The amount and the method for utilizing the capitation payment vary among the PPGs. Influencing the
capitation payment is the division of financial responsibility agreed to between Health Net and the PPG, as well as Member demographics and level of benefits.

In dual risk arrangements, the PPG will receive a capitation that covers some hospital or institutional services as well as professional services. In shared risk arrangements, the PPG will receive a capitation that covers only professional services.
While we contract with PPGs on a capitated basis, the PPGs contract with and reimburse both primary and specialty care physicians. These reimbursement methods include subcapitation, salary, and discounted fee schedules. In those instances where we contract
directly with physicians, the physician reimbursement is based on RBRVS (Resource Based Relative Value System), an industry accepted fee schedule that the Health Care Financing Administration (HCFA) established.

Who provides my health care
We are a Mixed Model HMO with an extensive network of over 600 participating physician groups and 415 hospitals conveniently located in the communities where you work or live. Over 36,000 primary care and referral specialist physicians are affiliated with us
through our participating physician groups.
You must select a participating physician group within a 30-mile radius of your home or work-site. Although each of your family members may select their own primary care physician, we encourage family members to choose their primary care physicians within
the same participating physicians group. This helps strengthen your family's doctor/ patient relationships.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we must
make available to you. Some of the required information is listed below.
Health Net is a for profit, Mixed Model (MMP) HMO that received certification as a Federally Qualified HMO in 1979 and was licensed by the California Department of Corporations in 1991.

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2002 HEALTH NET 7
If you want more information about us, call 1-800-522-0088, visit our website, www. healthnet. com, or write to:
Health Net P. O. Box 9103
Van Nuys, CA 91409-9103.

Service Area To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:

Full counties: Alameda, Colusa, Contra Costa, Glenn, Kings, Los Angeles, Madera, Marin, Mariposa, Merced, Napa,
Orange, Sacramento, San Diego, San Francisco, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz,
Sierra, Solano, Ventura, and Yolo counties, California.

Partial counties: El Dorado, Fresno, Kern, Mendocino, Nevada, Placer, Plumas, Riverside, San Bernardino, San Joaquin,
Sonoma, Stanislaus, Tehama, Trinity and Tulare counties, California. The following ZIP codes are those included in these
partial counties:

EL DORADO
95613-14
95619
95623

95633-36 95643
95651
95664 95667
95672
95682 95684
95709
95726-27 95762

FRESNO 93210
93234 93242
93602 93605-09

93611-13 93616
93621-22 93624-31
93634

93640-42 93646
93648-52 93654
93656-57

93660 93662
93664 93667-68
93675

93700-99

KERN 93203
93205-06 93215-17
93220 93222
93224-26

93238 93240-41
93243 93249-52
93255 93263

93268 93276
93280 93283
93285 93287-88

93300-91 93399
93501-05 93516
93518-19 93523-24

93531 93560-61
93581-82 93596

MENDOCINO 95415 95445 95449 95463 95482
NEVADA 95712
95924 95945-46 95949 95959-60 95975
PLACER 95602-04

95631 95648
95650

95658 95661
95663 95677-78
95681 95701
95703 95713-14
95717 95722
95736 95746-47
95765

PLUMAS 96103 96105-06 96122 96129 96135

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2002 HEALTH NET 8
RIVERSIDE
91718-20 91752

91760 92201-03
92210-11 92220
92223 92230
92234-36

92240-41 92253-55
92258 92260-64
92270 92274-76
92282 92302
92306 92313

92320 92330-31
92343-44 92348-49
92353 92355
92360-62 92367
92370 92380-81

92383 92387-88
92390 92395-96
92500-23 92530-32
92536 92539
92543-46 92548-57

92561-64 92567
92570-72 92581-93
92595-96 92860
92877-83

SAN BERNARDINO
91701 91708-10

91729-30 91737
91739 91743
91758-59

91761-64 91784-86
92252 92256
92268 92277-78
92284-86 92301

92305 92307-18
92314-18 92321-22
92324-27 92329
92333-37 92339-42

92345-47 92350
92352 92354
92356-59 92365
92368-69 92371-78

92382 92385-86
92391-94 92397-99
92400-27

SAN JOAQUIN 95201-13
95215-20 95227
95230-31

95234 95236-37
95240 95253
95258 95267-69
95290 95304
95320 95330-31
95336-37 95366
95376-78 95385
95686

SONOMA
94922-23 94926-28

94931 94951-55
94972 94975

94980-99 95400-09
95412-13 95416
95419 95421
95425

95430-31 95433
95436 95439
95441-42 95444
95446

95448 95450
95452 95462
95465 95471-73
95476

95480 95486-87
95492 95497

STANISLAUS 95307
95313 95316
95319

95323 95326
95328-29 95334
95350-58 95360-61
95363 95367-68
95374 95380-82
95384 95386-87

TULARE 93201
93207-08 93218-19
93221 93223
93227

93235 93237
93244 93247
93256-58 93260-62

93265 93267
93270-72 93274-75
93277-79 93282

93286 93291-92
93603 93615
93618 93647

93666 93670
93673-74

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2002 HEALTH NET 9
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
If you or a covered family member moves outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an
HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

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2002 HEALTH NET 10
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM (Section 8)

Changes to this Plan
Your share of the non-Postal premium will increase by 23. 7% for Self Only or 23. 7% for Self and Family.
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We changed the address for sending disputed claims to OPM (Section 8)
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We increased the non-formulary prescription drug copay to $35 at a retail pharmacy and $70 through mail order.
We now cover smoking cessation products that require a prescription
We decreased the copayment for home health care from $20 to $10 per visit after the first 30 visits.
We will no longer be offered in the following counties: Butte, Humboldt, Lake, Sutter, and Yuba

Section 2 10
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2002 HEALTH NET 11
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-522-0088.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, or coinsurance, and you will not have to file claims.
Plan providers Plan providers are participating physician groups, physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We maintain stringent credentialing and recredentialing criteria for our Plan Providers.

We list Plan providers in the provider directory, which we update periodically. The list is also on our web site.
Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our web site.

It depends on the type of care you need. First, you and each family member must choose a primary care physician from our network of participating physician groups. This
decision is important since your primary care physician provides or arranges for most of your health care.

You must select a Participating Physicians Group (PPG) within a 30 mile radius of your home or work-site. Each family member may choose their own PPG and primary care
physician.
You may transfer to another PPG by calling us at 1-800-522-0088. You may change PPG's once a month or upon our approval. All transfers will become effective on the
first day of the month following our receipt of the transfer, provided the request is received by the 14 th of the month. The request will be denied if you are more than three
months pregnant, confined to a hospital, in a surgery follow-up period (not yet released by the surgeon) or receiving treatment for an illness that is not yet complete.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see
a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Section 3

What you must do to get covered care 11
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2002 HEALTH NET 12
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see a participating
chiropractor (as described on page 23) and a woman may see her participating gynecologist at anytime without a referral.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your
treatment plan
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
You also have the right to request a second opinion when:
Your primary care physician or a referral physician gives a diagnosis or recommends a treatment plan that you are not satisfied with; or
You are not satisfied with the result of treatment you have received; or You are diagnosed with, or a treatment plan is recommended for a condition that
threatens loss of like, limb or bodily function, or a substantial impairment, including but not limited to a serious chronic condition; or
Your primary care physician or a referral physician is unable to diagnose your condition, or test results are conflicting.

Section 3 12
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2002 HEALTH NET 13
To request an authorization for a second opinion, contact your Primary Care Physician or Health Net Member Services at (800) 522-0088. Physicians at your Physician Group or
Health Net will review your request in accordance with Health Net's second opinion policy. You may obtain a copy of this policy from Health Net's Member Service
Department. All second opinions must be provided by a participating network physician who specializes in the illness, disease or condition associated with the request. If there is
no appropriately qualified physician in the network, your primary care physician will arrange for an out-of– network second opinion.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-522-0088. If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
Services that are not authorized by your primary care physician or Health Net will not be covered.

In addition, authorization by the Plan may be required for some formulary and non-formulary prescription drugs.

Section 3 13
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2002 HEALTH NET 14
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services.

Your catastrophic protection out-of-pocket maximum

for coinsurance and copayments After your copayments and coinsurance total $1,500 per person or $4, 500 per family enrollment in any calendar year, you do not have to pay any more for covered services.
However, copayments for the following services do not count toward your out-of-pocket maximum and you must continue to pay copayments for these services:

Prescription Drugs Chiropractic Care
Be sure to keep accurate records of your copayments and/ or coinsurance since you are responsible for informing us when you reach the maximum.

Section 4 14
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2002 HEALTH NET 15
Section 5. Benefits – OVERVIEW (See page 10 for how our benefits changed this year and page 58 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-522-0088 or at our website at www. healthnet. com.
(a) Medical services and supplies provided by physicians and other health care professionals ....................................................... 16-24
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies

Speech therapy Hearing services (testing, treatment, and
supplies) Vision services (testing, treatment, and
supplies) Foot care
Orthopedic and prosthetic devices Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals.................................................... 25-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ................................................................................. 29-31
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents.............................................................................................................................................. 32-33 Medical emergency Ambulance
(e) Mental health and substance abuse benefits......................................................................................................................... 34-35
(f) Prescription drug benefits............................................................................................................................................................ 36-38
(g) Special features ................................................................................................................................................................................. 39

Flexible benefits option Services for the Deaf and Hearing Impaired 24 Hour Nurse Line Early Prenatal Program
Centers of Excellence

(h) Dental benefits .................................................................................................................................................................................. 40
(i) Non-FEHB benefits available to Plan members................................................................................................................................ 41

Summary of benefits ................................................................................................................................................................................ 58

Section 5 15
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2002 HEALTH NET 16
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations

Second surgical opinion

$10 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility
In a physicians office for a newborn through the first 30 days of life

Nothing

In an urgent care center $35 per visit
At home $20 per visit

Not covered:
Treatment that is not authorized by a plan physician Treatment that is not medically necessary
All charges.

Section 5( a) 16
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2002 HEALTH NET 17
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if your receive these services during your office visit; otherwise, $10
per visit.

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening – every five years starting at age 50

Nothing if you receive these services during your office visit; otherwise, $10
per visit.

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing if you receive these services during your office visit; otherwise, $10
per visit
Routine pap test
Routine Mammogram covered for women age 35 and older, as
follows:
From age 35 through 39, one during this 5 year period
From age 40 through 64, one every calendar year
At age 65, one every two consecutive calendar years

Nothing if you receive these services during your office visit; otherwise, $10
per visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing

Immunizations for occupational and foreign travel: 20% of charges

Section 5( a) 17
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2002 HEALTH NET 18
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing if you receive these services during your office visit; otherwise, $10 per visit

Well-child care charges for routine examinations, and care (from 30 days old up to age 22)
Examinations, such as:
-Eye exams to determine the need for vision correction.
-Ear exams to determine the need for hearing correction
-Examinations done on the day of immunizations ( from 30 days old up to age 22)

$10 per office visit

Well-child care charges for routine examinations and care (birth through 30 days of life) Nothing
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 13 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).

Nothing

Section 5( a) 18
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2002 HEALTH NET 19
Family planning You pay
A broad range of voluntary family planning services, limited to:
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives, cervical caps and diaphragms under the prescription drug benefit.

Nothing

Voluntary sterilization (females) $150
Voluntary sterilization (males) $50
Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

50% of charges

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
Services and supplies related to excluded ART procedures

Cost of donor sperm, ova, or their collection or storage
Injectable medications for infertility treatments not covered by the plan

All charges.

Section 5( a) 19
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2002 HEALTH NET 20
Allergy care You pay
Testing and treatment

Allergy injection
Nothing

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Growth hormone therapy (GHT)

Nothing

Physical and occupational therapies
Services of the following are covered as long as significant improvement is expected for each condition:
-qualified physical therapists;
-occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or

injury.
Note: Occupational Therapy is limited to services to achieve and maintain self-care and improved functioning in activities of daily

living.

Nothing

Speech Therapy
Services for speech therapy are covered as long as significant improvement is expected for the condition. Nothing

Section 5( a) 20
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2002 HEALTH NET 21
Hearing Services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)

Not covered: all other hearing testing
hearing aids, testing and examinations for them
All charges.

Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery

(such as for cataracts)
$10 per office visit

Eye exam to determine the need for vision correction (see preventive care)
Annual eye refractions
$10 per office visit

Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eyeglasses or contact lenses after Interocular lens implant

All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges.

Section 5( a) 21
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2002 HEALTH NET 22
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Visual aids (excluding eyewear) to assist the visually impaired with proper dosing of insulin
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics, except when they have been incorporated into a cast, splint, brace or strapping of the foot

heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

prosthetic replacements provided less than 3 years after the last one we covered

All charges.

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
standard wheelchairs, electric wheelchairs if medically necessary;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Nothing

Section 5( a)
Durable Medical Equipment continued on next page 22
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2002 HEALTH NET 23
Durable medical equipment (DME) (continued) You pay Not covered:
Exercise equipment.
Hygienic equipment and supplies (to achieve cleanliness even when related to other covered medical services.

Stockings
Surgical dressings, except primary dressings that are applied by a Plan physician or a Hospital to lesions of the skin or surgical

incisions
Jacuzzis and whirlpools
Orthotics which are not custom made to fit your body (Orthotics are supports or braces for weak or ineffective joints or muscles.)

Foot orthotic, except when they have been incorporated into a cast, splint, brace or strapping of the foot.

All charges

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Note: Your Plan physician will review the home health service program for continuing appropriateness.

Nothing for the first 30 visits, $10 per visit thereafter.

Not covered: nursing care requested by, or for the convenience of, the patient or
the patient's family; home care primarily for personal assistance that does not include
a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Chiropractic treatments
Chiropractic services – by the chiropractors that participate in our ChiroNet network.

20 visits per calendar year are covered for these services without a referral from the Plan physician.
$10 per office visit

Chiropractic appliances are covered up to $50 per calendar year. All charges above $50 per calendar year

Section 5( a) 23
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2002 HEALTH NET 24
Alternative treatments You pay
Acupuncture – by a doctor of medicine or osteopathy for: pain relief $10 per office visit

Not covered: naturopathic services
hypnotherapy biofeedback
All charges.

Educational classes and programs
Coverage is limited to:
Diabetes self-management
Wellness programs provided by your selected Participating Physician Group

Online Smoking Cessation Program
Smoking Cessation Programs provided by your selected Provider Physician Group

WellChild Pregnancy Online Prenatal Program
Health Quotient personalized health profiling program.
Please visit out website at www. healthnet. com for more information.

Nothing

Section 5( a) 24
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2002 HEALTH NET 25
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.)

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)

Surgical treatment of morbid obesity
Insertion of internal prostethic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital
benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit, nothing for hospital visit

Voluntary Sterilization (Female) $150
Voluntary Sterilization (Male) $50 Surgical procedures continued on next page.

Section 5( b) 25
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2002 HEALTH NET 26
Surgical procedures (Continued) You pay Not covered:
Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care. All charges

Reconstructive surgery Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and

-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are protruding ear deformities, cleft lip, cleft palate, birth marks, webbed fingers, and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have this procedure performed on an inpatient basis and remain in the hospital
up to 48 hours after the procedure.

Nothing

Not covered: Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges

Section 5( b) 26
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2002 HEALTH NET 27
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

Not covered: Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges.

Section 5( b) 27
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2002 HEALTH NET 28
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach and pancreas.
Limited Benefits – Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved

clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Nothing

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Implants of artificial organs

Transplants not listed as covered

All charges

Anesthesia Professional services provided in –
Hospital (inpatient)
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing

Section 5( b) 28
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2002 HEALTH NET 29
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the

professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

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Benefit Description You pay
Inpatient hospital
Room and board, such as ward, semiprivate, or intensive care accommodations;

general nursing care; and meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate
room rate.

Nothing

Inpatient hospital continued on next page.

Section 5( c) 29
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2002 HEALTH NET 30
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Not covered: Custodial care
Non-covered facilities, such as nursing homes, schools Personal comfort items, such as telephone, television, barber
services, guest meals and beds Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures. Conditions for which hospitalization would be covered include hemophilia and heart disease: the need for
anesthesia by itself is not such a condition.

Nothing

Not covered: blood and blood derivatives replaced by the member All charges
Section 5( c) 30
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2002 HEALTH NET 31
Extended care benefits/ Skilled nursing care facility benefits You pay Extended care/ Skilled nursing facility (SNF): Up to 100 days per
calendar year for services such as: Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan
doctor

Nothing

Not covered: custodial care and personal comfort items such as telephone and television. All charges
Hospice care Hospice care: Up to 210 days for services such as:
Inpatient and outpatient care
Family counseling

Note: Hospice care services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with
a life expectancy of approximately six months or less

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ground and air ambulance service when medically appropriate Nothing

Section 5( c) 31
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2002 HEALTH NET 32
Section 5 (d). Emergency services/ accidents
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. An emergency will also include screening, examination and evaluation by a physician (or other health care professional acting within the scope of his or her license) to determine if a psychiatric medical emergency
condition exists and the treatment necessary to relieve or eliminate such condition, within the capability of the facility. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need
for quick action.
What to do in case of emergency:

Emergencies within our service area: If you are in an emergency situation, contact the local emergency system (i. e., the 911 telephone system) or go to the nearest hospital emergency room. Please call your Participating Physician Group. In extreme
emergencies, if you are unable to contact your medical group be sure to tell the emergency room personnel that you are a Health Net member so they can notify us at 1-800-522-0088. You or a family member should notify us within 48 hours, unless it was not
reasonably possible to do so. It is your responsibility to ensure that we have been notified in a timely manner.
If you need to be hospitalized, we must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in a non-Health Net facility and Health Net

doctors believe care can be better provided in a participating hospital, you will be transferred when medically feasible with any ambulance charges covered in full. Benefits are available for care from non-Health Net providers in a medical emergency only if
delay in reaching a participating provider would result in death, disability or significant jeopardy to your condition.
Any follow-up care recommended by non-Health Net providers must be approved by us or provided by our participating providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. If you need to be hospitalized, the Plan must be notified within 48 hours or on the
first working day following your admission, unless it was not reasonably possible to notify the plan within that time. If a Health Net doctor believes care can be better provided by a participating hospital, you will be transferred when medically feasible with
any ambulance charges covered in full.
Any follow-up care recommended by non-Health Net providers must be approved by us or provided by our participating providers.

Section 5( d) 32
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2002 HEALTH NET 33
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center or an emergency room
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Note: If the emergency results in admission to a hospital, the copay is waived

$35 per visit

Emergency care at your participating physician group's urgent care center $10 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office Emergency care at an urgent care center

Emergency care as an outpatient or inpatient at a hospital, including doctors' services
$35 per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Follow-up care not authorized by your participating physician group.

All charges.

Ambulance
Professional ground and air ambulance service when medically appropriate.

See 5( c) for non-emergency service.
Nothing

Section 5( d) 33
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2002 HEALTH NET 34
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits
for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan Provider and contained in a treatment plan approved by Managed Health

Network (MHN). The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan approved by Managed Health Network.

Your cost sharing responsibilities are no greater than for other illness or conditions.

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$10 per office visit

Mental health and substance abuse – Continued on next page

Section 5( e) 34
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2002 HEALTH NET 35
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing if you receive these services
during your office visit; otherwise $10 per visit.

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not

order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes. Contact MHN toll-free at 1-888-779-2236
twenty-four hours a day, seven days a week and MHN will direct you to the appropriate provider of care.

Limitation We may limit your benefits if you do not obtain a treatment plan.

Section 5( e) 35
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2002 HEALTH NET 36
Section 5 (f). Prescription drug benefits
I M
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a deductible.
Some formulary and non-formulary drugs require prior authorization from us. Contact us at 1-800-522-0088 to find out if your medication requires it and for information on what your physician must do to

obtain prior authorization.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or referral physician must write the prescription
Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail if a maintenance medication

We use a formulary. A formulary is the approved list of drugs that are covered. It identifies whether a generic version of a brand name drug exists, and if prior authorization is required. Drugs that are not excluded
or limited from coverage are also covered and are considered non-formulary drugs. Non-formulary drugs require a higher copayment.

You can get a copy of the formulary by calling us at 1-800-522-0088 or visit our web site at www. healthnet. com
We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from our formulary list. This list of name
brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost.
You can get a copy of the formulary by calling us at 1-800-522-0088 or visit our web site at www. healthnet. com

These are the dispensing limitations.
-When the prescription drug is filled at a Plan pharmacy: The pharmacy may dispense up to a 30-day
supply for each drug or for each refill at the appropriate time interval

-When the prescription drug is filled through the mail order program, the mail order pharmacy may
dispense up to a 90-day supply for each maintenance drug or refill allowed by the prescription order at the appropriate time interval.

If you send in an order too soon after the last one was filled, you will get a notice from the pharmacy indicating that it is too early to fill the prescription and when the next fill is available.
Mail order is for the dispensing of chronic medications that your physician has already approved for long term use. Not all drugs are available via mail order, such as
Drugs requiring immediate use that the delay in obtaining such drugs would interfere with the physician's treatment plan
Drugs requiring detailed instruction which cannot be provided by the mail order pharmacy compared to a retail pharmacist at the time the prescription is filled.

Section 5 (f) 36
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2002 HEALTH NET 37
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

The prescribed supply may not always be an appropriate drug treatment plan, according to the FDA or our usage guidelines. If this is the case, the amount of medication dispensed may be reduced.
If there is no generic equivalent available, you will still have to pay the brand name copayment.
Some formulary and non-formulary drugs may require prior authorization from us to be covered.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in
strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these
drugs meet the same standards of quality and strength as brand-name drugs.
When you have to file a claim. In most cases you do not have to file a claim when purchasing drugs at the Plan pharmacy. However, you must pay for the drug when it is dispensed, and file a claim for reimbursement
when the following occurs:
-Your Plan ID card is not available.

-Eligibility cannot be determined.
-The prescription drug is dispensed outside of California for a medical emergency.
For claims questions and assistance, or to request a prescription drug claim form or mail order request form, call us at 1-800-522-0088.

Section 5 (f) 37
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2002 HEALTH NET 38
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program: Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed as Not covered.
Insulin Diabetic supplies, such as blood glucose monitoring strips, Ketone
test strips and lancet. Disposable needles and syringes for the administration of covered
medications Drugs for sexual dysfunction (see limits below)
Contraceptive drugs and devices such as diaphragms and cervical caps

For drugs filled at a Plan pharmacy:
$5 for generic drugs
$10 for brand name drugs
$35 for non-formulary drugs
For drugs filled through the mail order program:

$10 for generic drugs
$20 for brand name drugs
$70 for non-formulary drugs
Note: If there is no generic equivalent available, you will still have to pay the

brand name copay.
Limited benefits: Drugs for sexual dysfunction are limited to 2 doses per week or 8 tablets

per month. Fertility drugs associated with covered services under the diagnosis and
treatment of infertility are covered under the Medical Services and Supplies Benefits (see page 19).

50% of charges

Not covered:
Drugs and supplies for cosmetic purposes
Medical supplies such as dressings and antiseptics
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Drugs available without a prescription or for which there is a nonprescription equivalent
Drugs to enhance athletic performance
Injectable Fertility Drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Anorectics (appetite suppressants), except for treatment of morbid obesity.
Non-prescription medications

All Charges

Section 5 (f) 38
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2002 HEALTH NET 39
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-474-6515 and talk with a registered nurse who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired. Please contact our Telecommunications Device for the Deaf at 1-800-995-0852.

Early Prenatal Program We encourage our mothers-to-be to participate in our special prenatal health program. Upon successful completion of the program, participants will receive an infant car seat. Parents learn answers to their early pregnancy concerns, such as caffeine or
alcohol use, tests during pregnancy and other general prenatal information. Please call 1-800-522-0088 for more information.

Centers of Excellence For organ and tissue transplants, we contract with premier transplant centers of excellence in Northern, Southern and Central California that have established their superior ability to perform certain transplant procedures. Your participating physician
group will work with you to find the best center for your condition.

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Section 5 (h). Dental benefits
I M
P O
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A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We have no calendar year deductible.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure

unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
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Accidental injury benefit You pay
We cover the restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services

must result from an accidental injury and treatment must be given within 24 hours of the injury.
Nothing at the dentist's office and a $35 copayment at the emergency room.

Not covered:
Damage to teeth while chewing food
Restorative services of the damaged tooth for cosmetic purposes
Follow-up treatment of an accidental injury to sound natural teeth

All charges

Dental benefits
Dental examinations and treatment of the gingival tissues (gums) when performed for the diagnosis or treatment of a tumor.

Not covered:
Other dental services not shown as covered

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Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Optional Dental and Vision Coverage The Vis-A-Dent product from Health Net subsidiaries DentiCare of California and AVP Vision Plans (DentiCare/ AVP) bundles dental and vision coverage together into a plan that provides access to
affordable, quality services. The plan offers a choice from two dental plans and combines it with a vision plan tailored to meet the needs of individuals and families. Two coverages, one bill.

Please note: The areas where Vis-A-Dent is offered may not be the same as the Health Net service area. Please call DentiCare/ AVP at 1-800-999-2848 for information about their service
area information.

Optional Indemnity Dental Coverage Standalone dental insurance is available through Health Net subsidiary, Foundation Health Systems Life and Health Insurance Company (FHS L& H). This indemnity dental plan covers a broad range of
services and allows you complete freedom of choice in selecting your dentist. This plan gives members an attractive combination of coverage, choice, and low cost.

Medicare Prepaid Plan Enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan (Health Net Seniority Plus
program) through Medicare. Annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available

in their area. They may then later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join Health Net Seniority Plus but will have to
pay for Medicare Part A in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for
information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 1-800-935-6565 for information on the Health Net Seniority Plus Medicare prepaid plan and the
cost of that enrollment. If you are eligible for Medicare and are interested in enrolling in a Medicare HMO sponsored by Health Net without dropping your enrollment in Health Net's FEHB plan, call 1-
800-935-6565 for information on the benefits available under the Medicare HMO.

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Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

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Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 1-800-522-0088.
When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be
itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Health Net, P. O. Box 9103 Van Nuys, CA 91409-9103

Prescription drugs When you purchase a prescription drug, and your Plan ID card is not available, eligibility cannot be determined, or the prescription is for a medical emergency outside of
California, you must pay for the drug when it is dispensed, and file a claim for reimbursement. For claims questions and assistance, or to request a prescription drug
claim form call us at 1-800-522-0088.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

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Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Health Net, P. O. Box 9103, Van Nuys, CA 91409-9103; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request— go to
step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E. Street, NW, Washington, D. C. 20415-3630.

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The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to
uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800-522-0088 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.

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Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-State Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for

premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan choices available to Medicare beneficiaries.
The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.

The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

We will not waive any of our copayments or coinsurance if we are the primary payer. If Medicare is the primary payer, we will waive some copayments or coinsurance when the Plan provider can expect
to receive payment amounting to more than any required copayment. (Chart on next page.)
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The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if

your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined

that you are unable to return to duty,
(except for claims related to Workers'

Compensation.)
B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and…

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or

c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.

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Claims process when you have the Original Medicare Plan – You probably will never have to file a claim form when you have both our Plan and the Original
MedicarePlan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will pay the

balance of covered charges. You will not need to do anything. To find out if you need to do something about filing your claims, call us at 1-800-522-0088.

We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a Medicare managed care plan.
These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not
waive any of our copayments, coinsurance or deductibles for your FEHB coverage.

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments or coinsurance. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium (OPM does not contribute to your Medicare managed care plan premium). For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the Medicare managed care service area.
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE
and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

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Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they
must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse us for any
expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

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Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 14.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care provided to assist in meeting the activities of daily living such as help in walking, getting in and out of bed, bathing, feeding, and supervision of
medications which are ordinarily self-administered.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 14.

Experimental or Experimental or investigational services are services that are not widely investigational services accepted or recognized within the organized medical community as standards of care.
Our Medical Policy Committee determines what procedures and services are experimental/ investigational using published peer review medical and surgical literature.
The procedure or service will be evaluated based on its health effects, safety, quality and cost effectiveness. In some cases, we use an independent medical review for expert
evaluation and determination of coverage.

Group health coverage Health coverage provided through a group policy, such as the FEHB program.
Medical necessity Medical necessity is the criteria used by us and the participating physician group to provide covered services in the prevention, diagnosis, and treatment of your illness or
condition. Medically necessary services are determined to be: Not experimental or investigational

Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness, or injury
Provided for the diagnosis or care and treatment of the condition, illness, or injury Not primarily for the convenience of the member, member's physician, or anyone else
The most appropriate supply or level of service that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting
is safe and adequate. Determination of whether services or supplies are medically necessary will be made
according to procedures we and the participating physician group have established.

Us/ We Us and we refer to Health Net
You You refers to the enrollee and each covered family member.

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Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family
member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

When benefits and The benefits in this brochure are effective on January 1. If you joined this plan during premiums start Open Season, your coverage begins on the first day of your first pay period that starts on
or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective
date of coverage.

Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

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OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and

subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you
do not meet this requirement, you may be eligible for other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you may be eligible

for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to
get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your
coverage choices.
Temporary Continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc..

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

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Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996. (HIPAA) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees
must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information.

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Long Term Care Insurance Is Coming Later in 2002
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or injury, or an age-related disease
such as Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing home care, care in an
assisted living facility, care in your home, adult day care, hospice care, and more. LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long term care, but the facts are that
about half them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc. We hope you will never need long term care, but everyone should have a plan just in
case. Many people now consider long term care insurance to be vital to their financial and retirement planing.

Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed $20,000 a year. And that's
before inflation! Long term care can easily exhaust your savings. Long term care insurance can
protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial care or a stay in an assisted
living facility or a continuing need for a home health aide to help you get in and out of bed and with other activities of daily living. Limited stays in skilled nursing
facilities can be covered in some circumstances. Medicare only covers skilled nursing home care (the highest level of nursing care)
after a hospitalization for those who are blind, age 65 or older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty guidelines, but has restrictions on covered services and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need? You should consider buying long-term care insurance.

What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?

When will I get more information on how to apply for this new
insurance coverage?

How can I find out more about the program NOW?

Long Term Care Insurance 54
54 Page 55 56
2002 HEALTH NET 55
Department of Defense/ FEHB Demonstration Project
What is it? The Department of Defense/ FEHB Demonstration Project allows some active and retired uniformed service members and their dependents to enroll in the FEHB Program. The
demonstration will last for three years and began with the 1999 open season for the year 2000. Open season enrollments will be effective January 1, 2002. DoD and OPM have set up some
special procedures to implement the Demonstration Project, noted below. Otherwise, the provisions described in this brochure apply.

Who is eligible DoD determines who is eligible to enroll in the FEHB Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for Medicare;
You are a dependent of an active or retired uniformed service member and are eligible for Medicare;

You are a qualified former spouse of an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.

If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program, you are not eligible to enroll under the DoD/ FEHBP Demonstration Project.

The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA
When you can join You may enroll under the FEHB/ DoD Demonstration Project during the 2001 open season, November 12, 2001, through December 10, 2001. Your coverage will begin January 1, 2002.
DoD has set-up an Information Processing Center (IPC) in Iowa to provide you with information about how to enroll. IPC staff will verify your eligibility and provide you with FEHB Program
information, plan brochures, enrollment instructions and forms. The toll-free phone number for the IPC is 1-877/ DOD-FEHB (1-877/ 363-3342).

You may select coverage for yourself (Self Only) or for you and your family (Self and Family) during open season. Your coverage will begin January 1, 2002. If you become eligible for the
DoD/ FEHB Demonstration Project outside of open season, contact the IPC to find out how to enroll and when your coverage will begin.

Department of Defense/ FEHB Demonstration Project continues on next page

DoD/ FEHB Demonstration Project 55
55 Page 56 57

2002 HEALTH NET 56
DoD has a web site devoted to the Demonstration Project. You can view information such as their Marketing/ Beneficiary Education Plan, Frequently Asked Questions, demonstration area locations
and zip code lists at www. tricare. osd. mil/ fehbp. You can also view information about the demonstration project, including "The 2002 Guide to Federal Employees Health Benefits Plans
Participating in the DoD/ FEHB Demonstration Project," on the OPM web site at www. opm. gov.

Temporary Continuation of coverage (TCC) See Section 11, FEHB Facts; it explains temporary continuation of coverage (TCC). Under this
DoD/ FEHB Demonstration Project the only individual eligible for TCC is one who ceases to be eligible as a "member of family" under your self and family enrollment. This occurs when a child
turns 22, for example, or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10, United States Code. For these individuals, TCC begins
the day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC enrollment terminates after 36 months or the end of the Demonstration Project, whichever occurs first. You,
your child, or another person must notify the IPC when a family member loses eligibility for coverage under the DoD/ FEHB Demonstration Project.

TCC is not available if you move out of a DoD/ FEHB Demonstration Project area, you cancel your coverage, or your coverage is terminated for any reason. TCC is not available when the
demonstration project ends.

Other features The 31-day extension of coverage and right to convert do not apply to the DoD/ FEHB Demonstration Project.

DoD/ FEHB Demonstration Project 56
56 Page 57 58
2002 HEALTH NET 57
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 32, 40 Allergy tests 20
Alternative treatment 24 Allogenetic (donor) bone marrow
Transplant 28 Ambulance 31
Anesthesia 28 Autologous bone marrow
transplant 28 Biopsies 25
Blood and blood plasma 30 Breast cancer screening 17
Casts 30 Changes for 2001 10
Chemotherapy 20 Childbirth 18
Chiropractic 23 Cholesterol tests 17
Claims 43 Coinsurance 14
Colorectal cancer screening 17 Congenital anomalies 26
Contraceptive devices and drugs 38 Coordination of benefits 47
Covered providers 11 Crutches 22
Deductible 14 Definitions 51
Diagnostic services 16 Disputed claims review 45
Donor expenses (transplants) 28 Dressings 38
Durable medical equipment (DME) 22
Educational classes and programs 24 Effective date of enrollment 52
Emergency 32

Experimental or investigational 50 Eyeglasses 21
Family planning 19 Fecal occult blood test 17
General Exclusions 42 Home health services 23
Hospice care 31 Home nursing care 23
Hospital 29 Immunizations 17
Infertility 19 Inhospital physician care 16
Inpatient Hospital Benefits 29 Insulin 38
Laboratory and pathological services 17
Machine diagnostic tests 17 Magnetic Resonance Imagings
(MRIs) 17 Mammograms 17
Mail Order Prescription Drugs 38 Maternity Benefits 18
Medically necessary 50 Medicare 46
Mental Conditions/ Substance Abuse Benefits 34
Newborn care 18 Non-FEHB Benefits 41
Nurse Licensed Practical Nurse 23 Nursery charges 18
Obstetrical care 18 Occupational therapy 20
Ocular injury 21 Oral and maxillofacial surgery 27
Orthopedic devices 22 Outpatient 30
Out-of-pocket maximum 14

Outpatient facility care 30 Oxygen 22
Pap Test 17 Physical examination 17
Physical therapy 20 Physician 11
Preventive care, adult 17 Preventive care, children 18
Prescription drugs 36, 42 Preventive services 17
Prior approval 13 Prostate cancer screening 17
Prosthetic devices 22 Psychologist 34
Radiation therapy 20 Renal dialysis 20
Room and board 29 Second surgical opinion 16
Skilled nursing facility care 31 Smoking cessation 24
Speech therapy 20 Splints 30
Sterilization procedures 25 Subrogation 48
Substance abuse 34 Surgery 25
Anesthesia 28 Oral 27
Reconstructive 26 Syringes 37
Transplants 28 Treatment therapies 20
Vision services 21 Well child care 18
Wheelchairs 22 X-rays 17
Workers' compensation 49

Index 57
57 Page 58 59
2002 HEALTH NET 58
Summary of benefits for Health Net HMO -2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................. Office visit copay: $10 (waived for maternity care) 16

Services provided by a hospital:
Inpatient ............................................................................................
Outpatient..........................................................................................

Nothing
Nothing

29

30
Emergency benefits:
In-area .............................................................................................
Out-of-area......................................................................................

$35 per visit (waived if admitted to hospital)
$35 per visit (waived if admitted to hospital)

32
32
Mental health and substance abuse treatment..................................... Regular cost sharing 34
Prescription drugs................................................................................. $5 copay for a 30 day supply of formulary generic drugs -$10 for a 90 day supply through
mail order.
$10 copay for a 30 day supply of formulary name brand drugs -$20 copay for a 90 day
supply through mail order.
$35 copay for a 30 day supply of non-formulary drugs -$70 for a 90 day supply through mail
order

36

Dental Care........................................................................................ Accidental injury benefit; nothing at the dentist's office or a $35 copay at the emergency
room.
40

Vision Care........................................................................................ $10 per visit; One refraction annually. 18
Special features: Early Bird Prenatal Program, Case Management Services, 24 hour nurse line to answer your health questions, Telecommunications Device for the Deaf, Centers of Excellence 39

Protection against catastrophic costs (your out-of-pocket maximum)......................................................... Nothing after $1,500/ Self Only or $4,500/ Family enrollment per year
Some costs do not count toward this protection
14

Summary 58
58 Page 59 60
2002 HEALTH NET 59
NOTES: 59
59 Page 60
2002 Rate Information for
Health Net

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to an FEHB Guide or contact the agency that maintains your health benefits enrollment.
Postal rates apply to career U. S. Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Diferent postal rates apply and special FEHB guides are published for Postal Service Nurses and Tool &
Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share Gov't Share Your Share

Self Only LB1 $86. 28 $28. 76 $186.94 $62. 31 $102.10 $12. 94
Self and Family LB2 $204.25 $68. 08 $442.54 $147.51 $241.69 $30. 64

11582 (9/ 01) 60

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