Download PrimeCare PPO – Members living outside California (pdf) PDF

TitlePrimeCare PPO – Members living outside California (pdf)
LanguageEnglish
File Size684.4 KB
Total Pages182
Document Text Contents
Page 1

CERTIFICATE
OF INSURANCE


A complete explanation of Your plan


PPO (Plan 4CR)

Important benefit information – please read
























PPO847LRG(1/13)

Page 91

(Florida LRG/SBG-2013)

2. The following benefits are added to the Additional Services and Supplies section of Your Certifi-
cate. These benefits are in addition to any coverage otherwise payable under the Medical Benefit.


Autism Spectrum Disorder

Coverage is provided for dependent children under age 18, and for dependent children age 18 or
over who have been diagnosed as having a developmental disability at age 8 or under.

Coverage includes speech therapy, occupational therapy, physical therapy and applied behavioral
analysis for treatment of autistic disorder, Asperger’s syndrome, and pervasive developmental dis-
order.

Coverage must be provided by an individual certified by the state of Florida to provide such ser-
vices.

Coverage is subject to a Calendar Year maximum of $36,000 and a lifetime maximum of $200,000.


Treatment of Cleft Lip and Cleft Palate

Coverage is provided for children under age 18 for treatment of cleft lip, cleft palate, or both. Cov-
erage includes medical, dental, speech therapy, audiology, and nutrition services if such services are
prescribed by the treating Physician or surgeon and such Physician or surgeon certifies that such
services are Medically Necessary and consequent to treatment of the cleft lip or cleft palate.


Osteoporosis Coverage

Coverage is provided for the Medically Necessary diagnosis and treatment of osteoporosis for high-
risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk
for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-
term glucocorticoid (steriod) therapy, individuals who have primary hyperparathyroidism and indi-
viduals who have a family history of osteoporosis.


3. The ELIGIBILITY, ENROLLMENT AND TERMINATION section of Your Certificate is revised

to delete the following from the Conversion Coverage provision:


You must request and complete an application form and send it to HNL within 31 days of the last
day of coverage.

and substitute the following:

You must request and complete an application form and send it to HNL within 63 days of
the last day of coverage.

Page 92

(Indiana LRG/SBG-2013)

(Attach this Certificate Amendment to Your Certificate of Insurance)


CERTIFICATE AMENDMENT


to the Certificate of Insurance




For: Covered Persons residing in Indiana


Your Certificate of Insurance is amended to conform to the requirements of the state of Indiana.

Any limitations and exclusions contained in Your Certificate of Insurance which are in conflict with these
requirements are hereby amended to comply with the minimum state requirements.

Benefits payable under this Amendment are reduced to the extent that benefits are payable for the same
expenses under the Medical Benefit or Outpatient Prescription Drug Benefit, if applicable.

The provisions on the following pages form part of this Certificate Amendment.

All other terms and conditions shown in Your Certificate of Insurance will continue to apply.




HEALTH NET LIFE INSURANCE COMPANY





S. Sell
President

Page 182

PPO847LRG(1/13)
Health Net Life Insurance Company is a subsidiary of Health Net, Inc.
Health Net® is a registered service mark of Health Net, Inc. All rights reserved.



Contact us

Health Net PPO
Post Office Box 10196
Van Nuys, California 91410-0196

Customer Contact Center
1-888-893-1572

1-800-331-1777 (Spanish)
1-877-891-9053 (Mandarin)
1-877-891-9050 (Cantonese)
1-877-339-8596 (Korean)
1-877-891-9051 (Tagalog)
1-877-339-8621 (Vietnamese)

Telecommunications Device for
the Hearing and Speech Impaired
1-800-995-0852


www.healthnet.com

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