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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesHealth Net of CA: Salud HMO y Mas Platinum A INFCoverage Period: 01/01/2018 – 12/31/20186/01/2018Coverage for: All Covered Members Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share thecost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.healthnet.com or call 1-800522-0088. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms seethe Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.healthnet.com or you can call 1-800-522-0088 to request a copy.Important QuestionsWhat is the overalldeductible?Are there servicescovered before youmeet your deductible?Are there otherdeductibles for specificservices?AnswersWhy This Matters: 0.See the Common Medical Events chart below for your costs for services this plan covers.No.You will have to meet the deductible before the plan pays for any services.No.You don’t have to meet deductibles for specific services.What is the out-ofpocket limit for thisplan? 2,000 per member / 4,000 per family throughSalud. 1,500 per member / 4,500 per familythrough SIMNSA. Salud & SIMNSA tiers crossaccumulate.The out-of-pocket limit is the most you could pay in a year for covered services. If you havefamily members in this plan, they have to meet their own out-of-pocket limits until the overallfamily out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Infertility Services, Premiums , balance billingcharges and health care this plan doesn’t cover.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.Will you pay less if youuse a networkprovider?This plan uses a provider network. You will pay less if you use a provider in the plan’sYes. For a list of preferred providers, seenetwork. You will pay the most if you use an out-of-network provider, and you might receive awww.healthnet.com/providersearch or call 1-800- bill from a provider for the difference between the provider’s charge and what your plan pays522-0088.(balance billing). Be aware, your network provider might use an out-of-network provider forsome services (such as lab work). Check with your provider before you get services.Do you need a referralto see a specialist?Yes. Requires written prior authorization.This plan will pay some or all of the costs to see a specialist for covered services but only ifyou have a referral before you see the specialist.EHI/B57/YLB/CDE/BO/18V1 of 6

6/01/2018All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedIf you visit a health careprovider’s office orclinicPrimary care visit to treatan injury or illnessSpecialist ic test (x-ray,blood work)Imaging (CT/PET scans,MRIs)If you have a testGeneric drugsPreferred brand drugsIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.healthnet.com/ca druglistNon-preferred branddrugsSpecialty drugsSIMNSA Network(Mexico members)What You Will PayHealth Net SaludSIMNSA NetworkNetwork (California(Self-referral formembers)California members)Limitations, Exceptions, & OtherImportant Information 5/visit 20/visit ––––––––– 5/visit 20/visit 5/visitNo chargeNo chargeNo chargeRequires prior authorization.You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check whatyour plan will pay for.No charge 20/visitNo chargeRequires referral.No charge 20/procedureNo chargeRequires prior authorization. 5/retail order 10/mail orderall generics exceptspecialty generics 20/retail order 40/mail order 50/retail order 100/mail order nonpreferred brandsonly 5 for drugsdispensed throughSIMNSA/retail orderNot covered/ mailorder 5 for drugsdispensed throughSIMNSA/retail orderNot covered/ mailorder 5 for drugsdispensed throughSIMNSA/retail orderNot covered/ mailorder30% coinsurance 5 for drugsdispensed throughSIMNSA/retail orderNot covered/ mailorderSupply/order: up to 30 day (retail); 35-90day (mail), except where quantity limitsapply. Prior authorization is required forselect drugs.Prior authorization is required for selectdrugs. Quantity limits may apply to selectdrugs. Supply/order: up to a 30 day supplyfilled by specialty pharmacy.Maximum out-of-pocket cost per 30 dayscript through Salud Network: 250* For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com2 of 6

CommonMedical EventServices You May NeedIf you have outpatientsurgeryIf you need immediatemedical attentionIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantSIMNSA Network(Mexico members)What You Will PayHealth Net SaludSIMNSA NetworkNetwork (California(Self-referral formembers)California members)6/01/2018Limitations, Exceptions, & OtherImportant InformationFacility fee (e.g.,ambulatory surgerycenter)No charge 350/procedureNo chargeRequires prior authorization.Physician/surgeon feesNo chargeNo chargeNo ��––––––––Emergency room careEmergency medicaltransportationUrgent careFacility fee (e.g., hospitalroom) 10/visit 100/visit 10/visitNo charge 50/transportNo charge 10/visit 20/visit 10/visitNo charge 350/admissionNo chargeRequires prior authorization.No chargeNo chargeNo ��––––––––Physician/surgeon feesCopay waived if admitted as an ––––––––––Copay waived if admitted as an inpatient.Inpatient servicesNo chargeOffice- 20/visitindividual therapysession 10/visit- grouptherapy sessionOther than office- Nocharge 350/admissionOffice visitsNo charge 20/visitNo chargeNo chargeNo chargeNo ��––––––––No charge 350/admissionNo ��––––––––Outpatient servicesChildbirth/deliveryprofessional servicesChildbirth/delivery facilityservicesOffice- 5/visitOther than officeNo chargeOffice- 5/visitOther than officeNo chargeNo chargePrior authorization required except for officevisits.Requires prior authorization.Prenatal and postnatal preventive servicesare covered under preventive care.* For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com3 of 6

CommonMedical EventServices You May NeedSIMNSA Network(Mexico members)Home health careIf you need helprecovering or haveother special healthneeds6/01/2018Limitations, Exceptions, & OtherImportant InformationLimited to 100 visits per calendar year.Requires prior authorization.Not coveredNo chargeNot coveredRehabilitation services 5/visit 20/visit 5/visitRequires prior authorization.Habilitation services 5/visit 20/visit 5/visitRequires prior authorization.Skilled nursing careNo charge 350/admissionNo chargeRequires prior authorization.Durable medicalequipmentNo charge30% coinsuranceNo chargeRequires prior authorization.Hospice servicesIf your child needsdental or eye careWhat You Will PayHealth Net SaludSIMNSA NetworkNetwork (California(Self-referral formembers)California members)No chargeNo chargeNo chargeChildren’s eye examNot coveredNo chargeNot coveredChildren’s glassesNot coveredNo chargeNot coveredChildren’s dental checkupNot coveredNo chargeNot coveredHospice care is covered in Mexico, but onlywhen services are provided in an acutehospital setting. Requires prior authorization.Limited to 1 visit per year.Provider selected frames; 1 per –––––––––––Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Chiropractic care Long term care Cosmetic surgery Dental care (Adult)Non-emergency services when travelling outsideU.S. Hearing aids Out-of-network services Private-duty nursing Routine foot care Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture (covered when medicallynecessary) Bariatric surgery Infertility treatment Routine eye care (Adult)* For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com4 of 6

6/01/2018Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s EmployeeBenefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Department of Health and Human Services, Center for ConsumerInformation and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.Other coverage options may be available to you too, including buyingindividual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-3182596.Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For moreinformation about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information tosubmit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health Net’s CustomerContact Center at 1-800-522-0088, submit a grievance form through www.healthnet.com, or file your complaint in writing to, Health Net Appeals and GrievanceDepartment, P.O. Box 10348, Van Nuys, CA 91410-0348. For information about group health care coverage subject to ERISA, contact the U.S. Department ofLabor’s Employee Benefits Security Administration at 1-866-444 (EBSA (3272) or www.dol.gov/ebsa/healthreform. If you have a grievance against Health Net, youcan also contact the California Department of Managed Health Care, at 1-800-HMO-2219 or www.hmohelp.ca.gov. For information about group health carecoverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444 (EBSA (3272) orwww.dol.gov/ebsa/healthreformDoes this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-0088.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-0088.Chinese (中文): � 1-800-522-0088.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' �––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next ––––––––* For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com5 of 6