(EOC) Health Net Health Net EOC Health Net (Affordable Care Act, ACA)

HMO HSP www.healthnet.com

(EOC) Health Net Health Net 1-877-609-8711 EOC Health Net (Affordable Care Act, ACA)

Health Net HMO CommunityCare Network CommunityCare Network Health Net HMO CommunityCare Network ( CommunityCare Network ) CommunityCare Network CommunityCare Network CommunityCare Network CommunityCare Network CommunityCare Network (PCP) Health Net Health Net HMO CommunityCare 1 CommunityCare Network 1 CommunityCare Network Health Net Health Net Health Net 1 CommunityCare Network (1) 30 (2) CommunityCare Network CommunityCare Network (3) Health Net CommunityCare Network CommunityCare Network Health Net CommunityCare Network www.healthnet.com Health Net 1-877-609-8711 Health Net CommunityCare Network Health Net Health Net CommunityCare Network CommunityCare Network 1

CommunityCare Network Health Net Health Net CommunityCare Network Community Care Network PCP Health Net 1-877-609-8711 2

Health Net PureCare HSP PureCare Network Health Net PureCare HSP ( PureCare Network ) PureCare HSP Network PureCare Network PureCare NetworK PureCare Network PureCare (PCP) Health Net Health Net PureCare HSP 1 PureCare Network 1 PureCare Network Health Net Health Net Health Net 1 PureCare Network PureCare Network Health Net PureCare HSP Network www.healthnet.com Health Net 1-877-609-8711 Health Net PureCare HSP Network Health Net Health Net PureCare Network PureCare Network PureCare Network Health Net Health Net PureCare Network PCP Health Net 1-877-609-8711 3

Health Net Health Net HMO (Individual & Family Plan Health Maintenance Organization, HMO) CommunityCare HMO (PCP) PCP HMO Health Net CommunityCare Network HSP (Health Care Service Plan, HSP) PureCare HSP PCP HSP Health Net PureCare Network HMO HMO PCP PCP Health Net CommunityCare PCP PCP Health Net PCP PCP Health Net CommunityCare PCP Health Net www.healthnet.com 1-877-609-8711 Health Net PCP PCP ID PCP PCP 4

Health Net PCP (HMO) (HSP) (HMO) (HSP) Health Net www.healthnet.com 1-877-609-8711 Health Net PCP PCP HSP Health Net HSP PureCare HSP Health Net PureCare HSP HSP PureCare HSP PCP PCP PCP Health Net PureCare HSP Health Net www.healthnet.com 1-877-609-8711 Health Net PCP PureCare HSP HSP HMO HSP HMO Plus HSP Plus 19 HMO Plus HSP Plus 5

(OOPM) OOPM OOPM 2 OOPM OOPM (a) OOPM (b) OOPM OOPM HMO Plus HSP Plus 19 OOPM HSP OOPM HSP OOPM HSP HSP Health Net $250 www.healthnet.com EOC 1. 1 2. 3. 4. (ABA) (BHT) 6 6 5. 6. 7. 8. 9. 10. 11. 12. 腭 13. 14. 15. 1 48 96 6

16. 17. (CPAP) 18. (EECP) 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. (TMJ) 31. 32. CT MRA MRI SPECT PET 33. Health Net www.healthnet.com 34. 12 35. $2,500 36. 37. 38. 39. 40. 41. 42. 43. 44. (GI) 7

45. 46. (UPPP) 47. 48. 49. X-STOP (DMHC) 28 1300.67.2.2 HMO HSP EOC Health Net 7 24 Health Net Health Net 8

19 2 Health Net 19 Health Net HMO Plus Health Net HSP Plus 19 Health Net Plus Health Net Health Net HMO HSP Plus Plus Health Net Health Net 1-800-909-3447 2 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net of California, Inc. Health Net EyeMed Vision Care, LLC EyeMed Vision Care, LLC Health Net of California, Inc. 9

Health Net Platinum 90 HMO CommunityCare HMO Health Net (EOC) Health Net Health Net 1 $4,000 $8,000 2 $15 2 $40 3 $15 2,4 $0 X $40 $20 CT PET MRI $150 $15 $250 $40 $250/ 5 / $40 5 $150/ 5 6 $150 $0 $15 $150 7 $250/ 5 / $40 $15/ $0 100 $20 10% $0 8 10% $250 9,10,11,12 30 I $5 II $15 III $25 IV 13 10% $250 14 $0 15 $0 1 10

EOC 1 (IHS) 300% 2 3 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 4 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 5 / / 5 6 5 7 MHN Services MHN Services 8 Health Net 9 $200 30 10 11 A B FDA Health Net (IUD) 12 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 13 IVSP Health Net 14 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 15 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 11

Health Net Gold 80 HMO CommunityCare HMO Health Net (EOC) Health Net Health Net 1 $6,750 $13,500 1 $30 1 $55 2 $30 1,3 $0 X $55 $35 CT PET MRI $275 $30 $600 $55 $600/ 5 /$55 4 $300/ 5 5 $325 $0 $30 $250 6 $600/ 5 $55 $30/$0 100 $30 20% $0 7 20% $250 8,9,10,11 30 I $15 II $55 III $75 IV 12 20% $250 13 $0 14 $0 1 12

EOC 1 2 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 3 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 4 / / 5 5 5 6 MHN Services MHN Services 7 Health Net 8 $200 30 9 10 A B FDA Health Net (IUD) 11 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 12 IVSP Health Net 13 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 14 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 13

Health Net Silver 70 HMO CommunityCare HMO Health Net (EOC) Health Net Health Net 1 1 $2,500 $5,000 $6,800 $13,600 2 $35 2 $70 3 $35 2,4 $0 X $70 $35 CT PET MRI $300 $35 20% 20% 20% $350 $0 $35 $250 5 20% $35 20% $35 100 $45 20% $0 6 20% $250 7.8,9,10,11 30 $250 $500 I $15 II $55 III $80 IV 12 20% $250 14

1 13 $0 14 $0 1 EOC 1 2 3 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 4 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 5 MHN Services MHN Services 6 Health Net 7 $200 30 8 9 I Health Net Health Net 10 A B FDA Health Net (IUD) 11 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 12 IVSP Health Net 13 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 14 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 15

Health Net Platinum 90 HSP PureCare HSP Health Net (EOC) Health Net Health Net 1 $4,000 $8,000 2 $15 2 $40 3 $15 2,4 $0 X $40 $20 CT PET MRI 10% $15 10% 10% 10% $150 10% $15 $150 5 10% $15 10% $15 100 10% 10% $0 6 10% $250 7,8,9,10 30 I $5 II $15 III $25 IV 12 10% $250 16

1 12 $0 13 $0 1 EOC 1 Health Net $250 EOC 2 3 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 4 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 5 MHN Services MHN Services 6 Health Net 7 $200 30 8 9 A B FDA Health Net IUD 10 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 11 IVSP Health Net 12 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 13 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 17

Health Net Gold 80 HSP PureCare HSP Health Net (EOC) Health Net Health Net 1 $6,750 $13,500 2 $30 2 $55 3 $30 2,4 $0 X $55 $35 CT PET MRI 20% $30 20% 20% 20% $325 $0 $30 $250 5 20% $30 20% $30 100 20% 20% $0 6 20% $250 7,8,9,10 30 I $15 II $55 III $75 IV 11 20% $250 18

Health Net Silver 70 HSP PureCare HSP Health Net (EOC) Health Net Health Net 1 2 $2,500 $5,000 $6,800 $13,600 3 $35 3 $70 4 $35 3,5 $0 X $70 $35 CT PET MRI $300 $35 20% 20% 20% $350 $0 $35 $250 6 20% $35 20% $35 100 $45 20% $0 7 20% $250 8,9,10,11 30 $250 $500 I $15 II $55 III $80 IV 12 20% $250 20

1 13 $0 14 $0 1 EOC 1 Health Net $250 EOC 2 3 4 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 5 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 6 MHN Services MHN Services 7 Health Net 8 $200 30 9 10 A B FDA Health Net IUD 11 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 12 IVSP Health Net 13 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 14 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 21

Health Net Bronze 60 HSP PureCare HSP Health Net (EOC) Health Net Health Net 1 2 $6,300 $12,600 $6,800 $13,600 3 1 3 $75 4 / 4 $75 3 1 3 $105 4 / 4 $105 5 1 3 $75 4 / 4 $75 3,6 $0 X 100% $40 CT PET MRI 100% $75 100% 100% 100% 100% $0 1 3 $75 4 / 4 $75 100% 7 100% $75 / 100% $75 100 100% 100% $0 8 100% $500 9,10,11,12 30 $500 $1,000 I 100% $500 II 100% $500 III 100% $500 22

1 IV 13 100% $500 14 15 $0 $0 1 EOC 1 Health Net $250 EOC 2 3 4 3 5 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 6 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 7 MHN Services MHN Services 8 Health Net 9 $200 30 10 11 A B FDA Health Net IUD 12 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 13 IVSP Health Net 14 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 15 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 23

Health Net Minimum Coverage HSP PureCare HSP Health Net (EOC) Health Net Health Net 1 2 $7,150 $14,300 $7,150 $14,300 3 1 3 0% 4 / 4 0% 3 0% 5 1 3 0% 4 / 4 0% 3,6 $0 X 0% 0% CT PET MRI 0% 0% 0% 0% 0% 0% $0 1 3 0% 4 / 4 0% 0% 7 0% 1-3 0% 4 / 4 0% 100 0% 0% 0% 8 0% 9,10,11,12 30 I $0 II $0 24

1 III $0 IV 13 $0 14 $0 15 $0 1 EOC 1 Health Net $250 EOC 2 3 4 3 5 Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) 6 A B (CDC) (ACIP) (HRSA) (FDA) (HPV) FDA 7 MHN Services MHN Services 8 Health Net 9 $200 30 10 11 A B FDA Health Net IUD 12 Health Net Health Net Health Net Health Net Health Net III Health Net Health Net 24 Health Net 72 Health Net ID Health Net www.healthnet.com Health Net II III IV 13 IVSP Health Net 14 Health Net of California, Inc. Dental Benefit Providers of California, Inc. (DBP) DBP Health Net EOC 15 Health Net of California, Inc. Health Net EyeMed Vision Care, LLC 25

Health Net 1-800-909-3447 Health Net (PCP) Health Net PCP www.healthnet.com > ProviderSearch 1-800-909-3447 Health Net 18 Health Net Health Net 30 Health Net Individual & Family Coverage 1150 Rancho Cordova, CA 95741-1150 Health Net (a) HMO Health Net CommunityCare HMO HSP PureCare HSP (b) 65 26 (a) (b) 65 Medicare (c) (c) Medi-Cal 2016 11 1 2017 1 31 60 Medi-Cal Medi-Cal 26

(a) (b) (c) (d) 36 (e) 180 Covered California TM 32 Covered California Covered California 308(c) 297 299.2 Health Net 60 Health Net 60 Health Net Health Net 1 Health Net Health Net 30 30 1 30 Health Net 30 27

/ Health Net ID Health Net 90 Health Net Health Net 24 Health Net Health Net Health Net Health Net 30 Health Net Health Net Health Net 28

Health Net Health Net Health Net Health Net Health Net 30 1. 2. 3. 4. 5. Health Net Health Net / 6. 180 Health Net / 1. Health Net 2. Health Net Health Net 3. Health Net Health Net Health Net 60 Health Net Health Net Health Net Health Net 29

Health Net 1-800-839-2172 Health Net Health Net Health Net I II III IV Health Net (a) (b) Health Net (c) (d) (e) Health Net Health Net Health Net Health Net Health Net 们 Health Net 1-877- 609-8711 Health Net Health Net 30 (IMR) IMR IMR (1-888-466-2219) TTY 30

(1-877-688-9891) http://www.hmohelp.ca.gov IMR HSP Health Net PureCare HSP HMO Health Net PCP PCP Health Net 1-877-609-8711 Health Net Health Net HMO HSP Health Net 2015 71.6% Health Net Health Net Health Net Health Net Health Net Health Net 60 Health Net Health Net 36 31

Health Net Health Net 30 30 Health Net ID Health Net 18 (a) (i) (ii) (b) (c) 1 7 26.5 7570 1-877-609-8711 Health Net HMO Health Net HSP Health Net Health Net ID 32

Health Net Health Net PCP HMO PCP Health Net ID Health Net 911 HMO HSP (a) (b) (c) (a) (b) 911 HMO Health Net 33

HSP Health Net (a) EOC (b) HMO 30 HSP Health Net Health Net Health Net Health Net 34

Health Net Health Net Health Net Health Net Health Net Health Net Health Net Health Net (IMR) Health Net Health Net 35

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MHN Services MHN Services Health Net Health Net ID Health Net (IPA) (HMO) (HSP) (HMO) (HSP) Health Net (HMO) (HSP) Health Net www.healthnet.com 1-877-609-8711 Health Net Health Net 90 CVS 1-877-609-8711 II Health Net 37

Health Net I II Health Net Health Net Health Net PCP Health Net Health Net (P&T) P&T P&T Health Net www. healthnet.com 1-877-609-8711 Health Net III III III IV IV Covered California IV SP www.healthnet.com Health Net IV IV Health Net IV IV Health Net PCP 38

I II III Health Net Health Net www. healthnet.com Health Net Health Net P&T Health Net Health Net Health Net EOC Health Net Caution - Limited by Federal Law to investigational use only Health Net Health Net 90 CVS Bronze Minimum Coverage Health Net 39

30 Health Net A B FDA (OTC) OTC Health Net Health Net FDA Health Net Health Net 30 8 Health Net Health Net Health Net American Specialty Health Plans of California, Inc. (ASH Plans) ASH Plans ASH Plans PCP 40

ASH Plans ASH Plans ASH Plans Health Net EOC MRI X X 41

18 Health Net Health Net EyeMed Vision Care, LLC EyeMed Vision Care EyeMed Vision Care 1-866-392-6058 Health Net www.healthnet.com $0 1 $55 9 1 Health Net (HMO) (HSP) EOC Health Net Health Net (HMO) (HSP) 42

12 $0 12 $0 $0 $0 2 6 / 3 $0 2 2-10D +10D 3D 20/25 Health Net 40% Health Net 43

18 Health Net Health Net ID EHB (EPSDT) HSP Minimum Coverage HSP Minimum Coverage $0 1 www.yourdentalplan.com/ healthnet 2 3 Health Net DHMO CA ONLY 4 5 Submit 44

Health Net (7) (24) 911 45

D0120 6 D0140 D0145 D0150 D0160 D0170 3 6 12 12 D0180 D0210 X 36 D0220 X 12 20 D0230 X 12 20 D0240 X 6 2 D0250 D0270 X D0272 X 6 D0273 X D0274 X 6 1 D0277 7 8 D0290 3 D0310 D0320 X 3 D0322 12 D0330 36 D0340 12 D0350 1 4 D0460 D0470 D0502 D0601 D0602 D0603 D0999 D1110 12 D1120 6 D1206 6 D1208 6 46

D1310 D1320 D1330 D1351 D1352 D1510 D1515 D1520 D1525 D1550 D1555 D2140 12 36 $25 $25 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 12 36 12 36 12 36 12 36 12 36 12 36 12 36 12 36 12 36 $30 $30 $40 $40 $45 $45 $30 $30 $45 $45 $55 $55 $60 $60 $50 $50 $30 $30 47

D2392 D2393 D2394 12 36 12 36 12 36 $70 - D2710 5 $140 D2712 ¾ 5 $190 D2721 5 $300 D2740 / 5 $300 D2751 5 $300 D2781 ¾ 5 $300 D2783 ¾ / 5 $310 D2791 5 $300 D2910 12 $25 D2915 $25 D2920 $25 D2929 / 12 $95 D2930 12 $65 D2931 36 $75 D2932 12 36 $75 $75 D2933 12 36 $80 $80 D2940 12 $25 D2950 $20 D2951 $25 D2952 $100 D2953 $30 D2954 $90 D2955 $60 D2957 $35 $40 $40 $50 $50 $70 48

D2971 $35 D2980 $50 D2999 $40 D3110 $20 D3120 $25 D3220 $40 D3221 $40 D3222 $60 D3230 $55 D3240 $55 D3310 $195 D3320 $235 D3330 $300 D3331 $50 D3332 $50 D3333 $80 D3346 $240 D3347 $295 D3348 $365 D3351 / $85 D3352 / D3351 $45 D3410 / $240 D3421 / $250 D3425 / $275 D3426 $110 D3430 $90 D3910 $30 D3999 $100 D4210 36 $150 D4211 36 $50 D4249 $165 D4260 36 $265 D4261 36 $140 49

D4265 $80 D4341 24 $55 D4342 24 $30 D4355 $40 D4381 $10 D4910 $30 D4920 $15 D4999 $350 D5110 5 $300 D5120 5 $300 D5130 $300 D5140 $300 D5211 5 $300 D5212 5 $300 D5213 $335 5 D5214 $335 5 D5410 12 $20 D5411 12 $20 D5421 12 $20 D5422 12 $20 D5510 12 $40 D5520 $40 12 D5610 12 $40 D5620 12 $40 D5630 12 $50 D5640 12 $35 50

D5650 $35 D5660 12 $60 D5730 12 $60 D5731 12 $60 D5740 12 $60 D5741 12 $60 D5750 12 $90 D5751 12 $90 D5760 12 $80 D5761 12 $80 D5850 36 $30 D5851 36 $30 D5862 $90 D5863 - $300 D5865 - $300 D5899 $350 D5911 $285 D5912 $350 D5913 $350 D5914 $350 D5915 $350 D5916 $350 D5919 $350 D5922 $350 D5923 $350 D5924 $350 D5925 $200 D5926 $200 D5927 $200 D5928 $200 D5929 $200 D5931 $350 D5932 $350 D5933 12 $150 D5934 $350 D5935 $350 D5936 $350 D5937 TMD $85 D5951 $135 D5952 $350 D5953 $350 51

D5954 $135 D5955 $350 D5958 $350 D5959 12 $145 D5960 12 $145 D5982 $70 D5983 $55 D5984 $85 D5985 $135 D5986 $35 D5987 $85 D5988 $95 D5991 $70 D5999 $350 D6010 $350 D6040 $350 D6050 $350 D6055 $350 D6056 $135 D6057 $180 D6058 / $320 D6059 $315 D6060 $295 D6061 $300 D6062 $315 D6063 $300 D6064 $315 D6065 / $340 D6066 $335 D6067 $340 D6068 / FPD $320 D6069 FPD $315 D6070 FPD $290 D6071 FPD $300 D6072 FPD $315 D6073 FPD $290 D6074 FPD $320 D6075 FPD $335 52

D6076 FPD $330 D6077 FPD $350 D6080 $30 D6090 $65 D6091 / D6092 / $25 D6093 / $35 D6094 $295 D6095 $65 D6100 $110 D6110 / $350 D6111 / $350 D6112 / $350 D6113 / $350 D6114 / $350 D6115 / $350 D6116 / $350 D6117 / $350 D6190 / $75 D6194 FPD $265 D6199 $350 D6211 5 $300 D6241 5 $300 D6245 / 5 $300 D6251 5 $300 D6721 5 $300 D6740 / 5 $300 D6751 5 $300 D6781 ¾ 5 $300 D6783 ¾ / 5 $300 D6791 5 $300 D6930 $40 $40 53

D6980 $95 D6999 $350 D7111 $40 D7140 $65 D7210 $120 D7220 $95 D7230 $145 D7240 $160 D7241 $175 D7250 $80 D7260 $280 D7261 $285 D7270 / $185 D7280 $220 D7283 $85 D7285 $180 D7286 3 $110 D7290 $185 D7291 / 嵴 $80 D7310 $85 D7311 $50 D7320 $120 D7321 $65 D7340 嵴 5 $350 D7350 嵴 $350 D7410 1.25 $75 D7411 1.25 $115 D7412 $175 D7413 1.25 $95 D7414 1.25 $120 D7415 $255 D7440 1.25 $105 54

D7441 1.25 $185 D7450 1.25 $180 D7451 1.25 $330 D7460 1.25 $155 D7461 1.25 $250 D7465 $40 D7471 $140 D7472 $145 D7473 $140 D7485 $105 D7490 $350 D7510 $70 D7511 $70 D7520 $70 D7521 $80 D7530 $45 D7540 $75 D7550 / $125 D7560 $235 D7610 $140 D7620 $250 D7630 $350 D7640 $350 D7650 / $350 D7660 / $350 D7670 嵴 $170 D7671 嵴 $230 D7680 $350 D7710 $110 D7720 $180 D7730 $350 D7740 $290 D7750 / $220 D7760 / $350 D7770 嵴 $135 D7771 嵴 $160 D7780 $350 55

D7810 $350 D7820 $80 D7830 $85 D7840 $350 D7850 / $350 D7852 $350 D7854 $350 D7856 $350 D7858 $350 D7860 $350 D7865 $350 D7870 $90 D7871 $150 D7872 $350 D7873 $350 D7874 $350 D7875 $350 D7876 $350 D7877 $350 D7880 $120 D7899 TMD $350 D7910 5 $35 D7911 5 $55 D7912 5 $130 D7920 $120 D7940 $160 D7941 $350 D7943 $350 D7944 $275 D7945 $350 D7946 LeFort I $350 D7947 LeFort I $350 D7948 LeFort II LeFort III $350 D7949 LeFort II LeFort III $350 D7950 $190 D7951 $290 D7952 $175 D7955 / $200 D7960 $120 D7963 $120 56

D7970 $175 D7971 $80 D7972 $100 D7980 $155 D7981 $120 D7982 $215 D7983 $140 D7990 $350 D7991 $345 D7995 $150 D7997 $60 D7999 $350 D8080 D8210 D8220 D8660 D8670 $1,000 D8680 D8691 D8692 D8693 D8999 D9110 $30 D9120 $95 D9210 $10 D9211 $20 D9212 $60 D9215 $15 D9223 15 $45 D9230 $15 D9243 15 $60 D9248 $65 D9310 $50 D9410 / $50 D9420 $135 (Current Dental Terminology ) 57

EOC / 19 12 19 Health Net (TMJ) 24 (1) 24 (2) 58

Health Net Health Net Health Net Health Net Health Net (HMO) (HSP) Health Net Health Net Health Net 3 (Medicare) EOC 19 3 60

Health Net EOC Health Net (a) (b) (c) (d) (e) (f) (g) EOC 100 Health Net Health Net A B FDA 61

Health Net Health Net Health Net Health Net Health Net Health Net Health Net (QAS) QAS QAS / Health Net Health Net (a) (b) (c) / 62

SED SMI Health Net Erhard / Health Net 63

HSP Health Net Health Net HMO Health Net 64

HMO Plus HSP Plus 19 HMO Plus HSP Plus HMO Plus HSP Plus Health Net Dental Benefit Providers of California, Inc. HMO Plus HSP Plus Health Net ID 1 www.yourdentalplan.com/healthnet 2 3 Health Net DHMO CA ONLY 4 5 Submit 15 1 1-866-249-2382 Health Net 65

D0120 D0140 D0150 D0210 X D0220 X D0230 X D0240 X D0270 X D0272 X D0273 X D0274 X 12 X D0330 X D0350 D0460 D0470 D0473 D0474 D0486 D1110 $8 D1110 $23 (a) 12 (b) 12 D1204 $3 D1206 $3 D1310 D1330 D1510 $75 66

1 D1515 $155 D1520 $100 D1525 $170 D1550 $15 D1555 $15 D2140 $25 D2150 $32 D2160 $41 D2161 $49 D2330 $35 D2331 $45 D2332 $55 D2335 $65 D2391 $55 D2392 $70 D2393 $85 D2394 $85 - D2710 $240 D2712 3/4 $240 D2720 $240 D2721 $240 D2722 $240 D2750 $305 D2751 $305 D2752 $305 D2780 3/4 $280 67

1 - D2781 3/4 $280 D2782 3/4 $280 D2790 $280 D2791 $280 D2792 $280 D2794 $280 D2910 $15 D2915 $15 D2920 $21 D2930 $55 D2931 $65 D2940 $20 D2950 $23 D2951 $20 D2952 $100 D2953 $100 D2954 $60 D2957 $60 D2970 D3110 $21 D3120 $21 D3220 $33 D3310 $170 D3320 $220 D3330 $290 D3332 $170 68

1 D3346 $185 D3347 $240 D3348 $315 D3410 $155 D3421 $155 D3425 $155 D3426 $75 D3430 $48 D3450 $85 D3920 $85 D4210 $230 D4211 $33 D4240 $30 D4241 $30 D4260 $290 D4261 $290 D4341 $30 D4342 $30 D4355 $20 D5110 $405 D5120 $405 D5130 $420 D5140 $420 D5211 $290 D5212 $290 D5213 $385 D5214 $385 D5410 $15 D5411 $15 D5421 $15 D5422 $15 D5510 $45 69

1 D5520 $53 D5610 $45 D5620 $58 D5630 $63 D5640 $53 D5650 $58 D5660 $63 D5710 $185 D5711 $185 D5720 $185 D5721 $185 D5730 $70 D5731 $70 D5740 $70 D5741 $70 D5750 $120 D5751 $120 D5760 $120 D5761 $120 D5820 $135 D5821 $135 D5850 $40 D5851 $40 D6205 $280 D6210 $280 D6211 $280 D6212 $280 D6214 $305 D6240 $305 D6241 $305 D6242 $305 70

1 D6710 $305 D6750 $305 D6751 $305 D6752 $305 D6780 3/4 $280 D6781 3/4 $280 D6782 3/4 $280 D6790 $280 D6791 $280 D6792 $280 D6794 $280 D6930 $23 D6970 $100 D6972 $60 D6973 $23 D6976 $100 D6977 $60 D9120 D7111 $35 D7140 $35 D7140 / $27 71

1 D7140 / D7210 $50 D7220 $70 D7230 $105 D7240 $135 D7250 $50 D8090 $1,800 D8210 $115 D8220 $220 D8670 $17 D9110 $14 D9930 $11 D9951 $27 D9952 $27 D9999 24 $20 (a) 24 (b) D9999 X D9999 X D9999 Health Net (Current Dental Terminology ) $43 72

Health Net ID HMO Plus HSP Plus Plus HMO Plus HSP Plus (a) 12 (b) 12 X 36 12 / Health Net 12 12 X 73

24 (a) 24 (b) / EOC 24 (1) 24 (2) Health Net 19 $1,800 20 $2,000 24 Health Net (TMJ) 74

HMO Plus HSP Plus 19 HMO Plus HSP Plus Health Net of California, Inc. Health Net EyeMed Vision Care, LLC HMO Plus HSP Plus www.healthnet.com ProviderSearch 1-866-392-6058 Health Net HMO Plus HSP Plus 75

HMO Plus HSP Plus $10 $55 9 12 $80 $0 12 $40 $40 $40 $40 $105 $105 80% $120 8 8 8 8 8 8 12 2 $0 $80 $0 15% $80 $0 12 1 20/40-12 D +9 D 3D (2) 76

12 $80 20% 80% Health Net $80 40% Health Net HMO Plus Health Net HSP Plus HMO Plus HSP Plus Health Net (1) (2) Health Net 77

Health Net of California, Inc.(Health Net) Health Net Health Net 1-800-522-0088 711 Health Net Health Net Health Net Health Net of California, Inc., PO Box 10348, Van Nuys, California 91410-0348 1-877-831-6019 healthnet.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201 1-800-368-1019 1-800-537-7697 http://www.hhs.gov/ocr/office/file/index.html

English No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or call 1-800-522-0088 (TTY: 711). If you bought coverage through the California marketplace call 1-888-926-4988 (TTY: 711). For more help: If you are enrolled in a PPO or EPO insurance policy from Health Net Life Insurance Company, call the CA Dept. of Insurance at 1-800-927-4357. If you are enrolled in an HMO or HSP plan from Health Net of California, Inc., call the DMHC Helpline at 1-888-HMO-2219. Arabic خدمات اللغة مجانية. يمكنك الحصول على مترجم فوري. ويمكنك الحصول على وثائق مقروءة لك. للحصول على المساعدة اتصل بنا على الرقم الموجود على بطاقة الهوية أو اتصل على مركز االتصال التجاري في 1-800-522-0088 )711.)TTY: في حال قمت بشراء التغطية من سوق كاليفورنيا اتصل على الرقم 1-888-926-4988 )711 )TTY: وللحصول على المساعدة: في حال كنت مسجال في بوليصة تأمين المنظمة المزودة المفضلة PPO أو المنظمة المزودة الحصرية EPO من شركة التأمين على الحياة Health Net Life Insurance Company اتصل على قسم التأمين في كاليفورنيا على الرقم 1-800-927-4357. في حال كنت مسجال في منظمة المحافظة على الصحة HMO أو خطة التوفير الصحية HSP من شركة,.Health Net of California, Inc اتصل على خط المساعدة في قسم الرعاية الصحية المدارة DMHC على الرقم.1-888-HMO-2219 Armenian Անվճար լեզվական ծառայություններ: Դուք կարող եք բանավոր թարգմանիչ ստանալ: Փաստաթղթերը կարող են կարդալ ձեզ համար: Օգնության համար զանգահարեք մեզ ձեր ID քարտի վրա նշված հեռախոսահամարով կամ զանգահարեք 1-800-522-0088 (TTY: 711) հեռախոսահամարով: Եթե ապահովագրում եք գնել Կալիֆորնիայի շուկայական հրապարակի միջոցով, զանգահարեք 1-888-926-4988 (TTY: 711) հեռախոսահամարով: Լրացուցիչ օգնության համար. եթե անդամագրված եք Health Net Life Insurance Company-ի PPO կամ EPO ապահովագրությանը, զանգահարեք Կալիֆորնիայի Ապահովագրության բաժին 1-800-927-4357 հեռախոսահամարով: Եթե անդամագրված եք Health Net of California, Inc.-ի HMO կամ HSP ծրագրին, զանգահարեք DMHC օգնության գիծ 1-888-HMO-2219 հեռախոսահամարով: Chinese 免費語言服務您可使用口譯員您可請人使用您的語言將文件內容唸給您聽, 並請我們將有您語言版本的部分文件寄給您如需協助, 請致電您會員卡上所列的電話號碼與我們聯絡, 或致電 1-800-522-0088(TTY:711) 如果您是透過加州健康保險交易市場購買承保, 請致電 1-888-926-4988(TTY:711) 如需進一步協助 : 如果您透過 Health Net Life Insurance Company 投保 PPO 或 EPO 保單, 請致電 1-800-927-4357 與加州保險局聯絡如果您透過 Health Net of California, Inc. 投保 HMO 或 HSP 計畫, 請致電 DMHC 協助專線 1-888-HMO-2219 Hindi ब न ल गत व ल भ ष स व ए आप एक द भ बषय प प त कर सकत ह आपक दसत व ज पढ कर स न ए ज सकत ह मदद क ललए, आपक आईड क ड ड पर ददए गए स च द ध न र पर हम क ल कर, य 1-800-522-0088 (TTY: 711) पर क ल कर यदद आपन क ललफ लन डय म दक ड ट पल स क म धयम स कवर ज खर द ह त 1-888-926-4988 (TTY: 711) पर क ल कर अल क मदद क ललए: यदद आप Health Net Life Insurance Company प प ओ PPO य ईप ओ EPO म प ललस म न म दकत ह, त क ललफ लन डय म बवभ ग क 1-800-927-4357 पर क ल कर यदद आप Health Net of California, Inc. क एचएमओ HMO य एचएसप HSP पल न म न म दकत ह, त ड एमएचस DMHC ह लपल इन क 1-888-HMO-2219 पर क ल कर 80

Hmong Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom yog koj hom lus los tau. Kev pab, hu rau peb ntawm tus xov tooj teev nyob rau hauv koj daim ID card los yog hu rau 1-800-522-0088 (TTY: 711). Yog tias koj yuav kev pov hwm ntawm California marketplace hu 1-888-926-4988 (TTY: 711). Xav tau kev pab ntxiv: Yog koj tau tsab ntawv tuav pov hwm PPO los yog EPO los ntawm Health Net Life Insurance Company, hu mus rau CA Dept. of Insurance ntawm 1-800-927-4357. Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219. Japanese 無料の言語サービス通訳をご利用いただけます日本語で文書をお読みします援助が必要な場合は ID カードに記載されている番号までお電話いただくか 1-800-522-0088 (TTY: 711) までお電話くださいカリフォルニア州のマーケットプレイス ( 保険購入サイト ) を通じて保険を購入された方は 1-888-926-4988 (TTY: 711) までお電話くださいさらに援助が必要な場合 :Health Net Life Insurance Company の PPO または EPO 保険ポリシーに加入されている方はカリフォルニア州保険局 1-800-927-4357 まで電話でお問い合わせください Health Net of California, Inc. の HMO または HSP に加入されている方は DMHC ヘルプライン 1-888-HMO-2219 まで電話でお問い合わせください Khmer ស វ ភ ស ស យឥតគ តថ ល អ នកអ ចទទ លប នអ នកបកប បផ ទ ល ម ត អ នកអ ចស ដ ប សគអ នឯកស រឱ យអ នក ម ប ជ ន យ មទ ក ទងសយ ងខ ញ ត មរយ សលខទ រ ពទ ប លម នស សល ក ត ម គ ល ខល នរប អ នក ឬ ទ ក ទងស ម ជ ឈមណ ឌ លទ ន ក ទ នងព ណ ជ ជកម មថន ករ មហ ញន 1-800-522-0088 (TTY: 711) សប នអ នកប នទ ញក រធ ន រ ប រ ងត មរយ ទ ផ ស រថនរ ឋក ល ហ វ រញ មទ រ ពទ ស សលខ 1-888-926-4988 (TTY: 711) ម ប ជ ន យបបនថ ម សប នអ នកប នចញ ស ម ក ន ញងស លក រណ ធ ន រ ប រង PPO ឬ EPO ព ករ មហ ញនធ ន រ ប រងជ វ ត Health Net Life Insurance Company មទ ក ទងស ន យក ឋ នធ ន រ ប រង CA ត មរយ ទ រ ពទ សលខ 1-800-927-4357 សប នអ នកប នចញ ស ម ក ន ញងបផ នក រ HMO ឬ HSP ព ករ មហ ញន Health Net of California, Inc. ថនរ ឋក ល ហ វ រញ មទ ក ទងសលខទ រ ពទ ជ ន យ DMHC 1-888-HMO-2219 Korean 무료언어서비스. 통역서비스를받을수있습니다. 문서낭독서비스를받으실수있습니다. 도움이필요하시면보험 ID 카드에수록된번호로전화하시거나 1-800-522-0088 (TTY: 711) 번으로전화해주십시오. 캘리포니아주마켓플레이스를통해보험을구입하셨으면 1-888-926-4988 (TTY: 711) 번으로전화해주십시오. 추가도움이필요하시면, Health Net Life Insurance Company 의 PPO 또는 EPO 보험에가입되어있으시면캘리포니아주보험국에 1-800-927-4357 번으로전화해주십시오. Health Net of California, Inc. 의 HMO 또는 HSP 플랜에가입되어있으시면 DMHC 도움라인에 1-888-HMO-2219 번으로전화해주십시오. Navajo Saad Bee!k1 E eyeed T 11 J77k e. Ata halne 7g77 h0l=. T 11 h0 hazaad k ehj7 naaltsoos hach 8 w0ltah. Sh7k1 a doowo[ n7n7zingo naaltsoos bee n47ho d0lzin7g77 bik1a gi b44sh bee hane 7 bik11 1aj8 hod77lnih 47 doodaii 1-800-522-0088 (TTY: 711). California marketplace hooly4h7j7 b4eso 1ch 33h naanil7 ats 77s baa 1h1y3 biniiy4 nah7n7[nii go 47 koj8 h0lne 1-888-926-4988 (TTY: 711). Sh7k1 an11 doowo[ jin7zingo: PPO 47 doodaii EPO-j7 Health Net Life Insurance Company woly4h7j7 b4eso 1ch 33h naa nil biniiy4 hwe iina bik 4 4sti go 47 CA Dept. of Insurance bich 8 hojilnih 1-800-927-4357. HMO 47 doodaii HSP-j7 Health Net of California, Inc.-j7 b4eso 1ch 33h naa nil biniiy4 hats 77s bik 4 4sti go 47 koj8 hojilnih DMHC Helpline 1-888-HMO-2219. 81

Persian (Farsi) خدمات زبان به طور رايگان. می توانيد يک مترجم شفاهی بگيريد. می توانيد درخواست کنيد که اسناد برای شما قرائت شوند. برای دريافت راهنمايی با ما به شماره ای که روی کارت شناسايی شما درج شده تماس بگيريد يا با مرکز تماس بازرگانی )711 1-800-522-0088 )TTY: تماس بگيريد. اگر پوشش بيمه را از طريق بازارگاه کاليفرنيا خريداری کرديد با شماره )711 1-888-926-4988 )TTY: تماس بگيريد. برای دريافت راهنمايی بيشتر: اگر در بيمه نامه PPO يا EPO از سوی Healthعضويت Net Life Insurance Company داريد با CA Dept. of Insurance به شماره 1-800-927-4357 تماس بگيريد. اگر در برنامه HMO يا HSP از سوی.Health Net of California, Inc عضويت داريد با خط راهنمايی تلفنی DMHC به شماره 1-888-HMO-2219 تماس بگيريد. Panjabi (Punjabi) ਬ ਨ ਬ ਸ ਲ ਗਤ ਤ ਭ ਸ ਸ ਵ ਵ ਤ ਸ ਇ ਦ ਭ ਬਸਆ ਪ ਪਤ ਰ ਸ ਦ ਹ ਤ ਹ ਨ ਦਸਤ ਵ ਜ ਤ ਹ ਡ ਭ ਸ ਬਵ ਚ ਪੜ ਹ ਸ ਣ ਏ ਜ ਸ ਦ ਹਨ ਮਦਦ ਲਈ, ਆਪਣ ਆਈਡ ਰਡ ਤ ਬਦ ਤ ਨ ਰ ਤ ਸ ਨ ਲ ਰ ਜ ਬ ਰਪ ਰ 1-800-522-0088 (TTY: 711) ਤ ਲ ਰ ਜ ਤ ਸ ਲ ਫ ਰਨ ਆ ਮ ਰਬ ਟ ਪਲ ਸ ਦ ਰ ਹ ਮ ਵਰ ਜ ਖਰ ਦ ਹ ਤ 1-888-926-4988 (TTY: 711) ਤ ਲ ਰ ਵਧ ਰ ਮਦਦ ਲਈ: ਜ ਤ ਸ Health Net Life Insurance Company ਪ ਪ ਓ PPO ਜ ਈਓਪ EPO ਮ ਪ ਬਲਸ ਬਵ ਚ ਨ ਮ ਬ ਤ ਹ, ਤ ਲ ਫ ਰਨ ਆ ਮ ਬਵਭ ਗ ਨ 1-800-927-4357 ਤ ਲ ਰ ਜ ਤ ਸ Healh Net of California, Inc. ਤ ਇ ਐਚਐਮਓ HMO ਜ ਐਚਐਸਪ HSP ਪਲ ਨ ਬਵ ਚ ਨ ਮ ਬ ਤ ਹ ਤ ਡ ਐਮਐਚਸ DMHC ਹ ਲਪਲ ਈਨ ਨ 1-888-HMO-2219 ਤ ਲ ਰ Russian Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут прочитать документы. За помощью обращайтесь к нам по телефону, приведенному на вашей идентификационной карточке участника плана. Кроме того, вы можете позвонить в 1-800-522-0088 (TTY: 711). Если свою страховку вы приобрели на едином сайте по продаже медицинских страховок в штате Калифорния, звоните по телефону 1-888-926-4988 (TTY: 711). Дополнительная помощь: Если вы включены в полис PPO или EPO от страховой компании Health Net Life Insurance Company, звоните в Департамент страхования штата Калифорния (CA Dept. of Insurance), телефон 1-800-927-4357. Если вы включены в план HMO или HSP от страховой компании Health Net of California, Inc., звоните по контактной линии Департамента управляемого медицинского обслуживания DMHC, телефон 1-888-HMO-2219. Spanish Servicios de idiomas sin costo. Puede solicitar un intérprete. Puede obtener el servicio de lectura de documentos y recibir algunos en su idioma. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o comuníquese con el Centro de Comunicación Comercial de Health Net, al 1-800-522-0088 (TTY: 711). Si adquirió la cobertura a través del mercado de California, llame al 1-888-926-4988 (TTY: 711). Para obtener más ayuda, haga lo siguiente: Si está inscrito en una póliza de seguro PPO o EPO de Health Net Life Insurance Company, llame al Departamento de Seguros de California, al 1-800-927-4357. Si está inscrito en un plan HMO o HSP de Health Net of California, Inc., llame a la línea de ayuda del Departamento de Atención Médica Administrada, al 1-888-HMO-2219. 82

Tagalog Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga dokumento na babasahin sa inyo. Para sa tulong, tawagan kami sa nakalistang numero sa inyong ID card o tawagan ang 1-800-522-0088 (TTY: 711). Kung bumili kayo ng pagsakop sa pamamagitan ng California marketplace tawagan ang 1-888-926-4988 (TTY: 711). Para sa higit pang tulong: Kung nakatala kayo sa insurance policy ng PPO o EPO mula sa Health Net Life Insurance Company, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. Kung nakatala kayo sa HMO o HSP na plan mula sa Health Net of California, Inc., tawagan ang Helpline ng DMHC sa 1-888-HMO-2219. Thai ไม ม ค าบร การด านภาษา ค ณสามารถใช ล ามได ค ณสามารถให อ านเอกสารให ฟ งได ส าหร บความช วยเหล อ โทรหาเราตาม หมายเลขท ให ไว บนบ ตรประจ าต วของค ณ หร อ โทรหาศ นย ต ดต อเช งพาณ ชย ของ 1-800-522-0088 (TTY: 711) หากค ณ ซ อความค มครองผ านทาง California marketplace โทร 1-888-926-4988 (TTY: 711) ส าหร บความช วยเหล อเพ มเต ม หาก ค ณสม ครท ากรมธรรม ประก นภ ย PPO หร อ EPO ก บ Health Net Life Insurance Company โทรหากรมการประก นภ ยร ฐ แคล ฟอร เน ยได ท 1-800-927-4357 หากค ณสม ครแผน HMO หร อ HSP ก บ Health Net of California, Inc. โทรหาสายด วน ความช วยเหล อของ DMHC ได ท 1-888-HMO-2219. Vietnamese Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho nghe tài liệu. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID của quý vị hoặc gọi 1-800-522-0088 (TTY: 711). Nếu quý vị mua khoản bao trả thông qua thị trường California 1-888-926-4988 (TTY: 711). Để nhận thêm trợ giúp: Nếu quý vị đăng ký hợp đồng bảo hiểm PPO hoặc EPO từ Health Net Life Insurance Company, vui lòng gọi Sở Y Tế CA theo số 1-800-927-4357. Nếu quý vị đăng ký vào chương trình HMO hoặc HSP từ Health Net of California, Inc., vui lòng gọi Đường Dây Trợ Giúp DMHC theo số 1-888-HMO-2219. 83

Health Net PO Box 1150 Rancho Cordova, CA 95741-1150 1-877-609-8711 1-877-891-9053 1-877-339-8596 1-877-891-9053 1-800-331-1777 1-877-891-9051 1-877-339-8621 711 www.healthnet.com Health Net HMO HSP Health Net of California, Inc. Health Net of California, Inc. Health Net, Inc. Health Net Health Net, Inc. Covered California BKT010388CP00 (1/17)