Plan Materials and Forms

Listed below are some documents that may be helpful at different times during your membership.

For HMO Members
Plan	CMS#	County	Summary of Benefits
Health Net Gold Select (HMO)	H0562 - 101-001	Los Angeles & Orange	Summary of Benefits, H0562 - 101-001 - English (PDF) Summary of Benefits, H0562 - 101-001 - Spanish (PDF) Summary of Benefits, H0562 - 101-001 - Chinese (PDF)
Health Net Gold Select (HMO)	H0562 - 101-002	Riverside & San Bernardino	Summary of Benefits, H0562 - 101-002 - English (PDF) Summary of Benefits, H0562 - 101-002 - Spanish (PDF) Summary of Benefits, H0562 - 101-002 - Chinese (PDF)
Health Net Seniority Plus Green (HMO)	H0562 - 044	Los Angeles, Riverside & San Bernardino	Summary of Benefits, H0562 - 044 - English (PDF) Summary of Benefits, H0562 - 044 - Spanish (PDF)
Health Net Seniority Plus Green (HMO)	H0562 - 045	Alameda, Placer, Sacramento & Stanislaus	Summary of Benefits, H0562 - 045 - English (PDF) Summary of Benefits, H0562 - 045 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 068	Alameda & Stanislaus	Summary of Benefits, H0562 - 068 - English (PDF) Summary of Benefits, H0562 - 068 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 090	Fresno	Summary of Benefits, H0562 - 090 - English (PDF) Summary of Benefits, H0562 - 090 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-001	Los Angeles & Orange	Summary of Benefits, H0562 - 100-001 - English (PDF) Summary of Benefits, H0562 - 100-001 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-002	Riverside & San Bernardino	Summary of Benefits, H0562 - 100-002 - English (PDF) Summary of Benefits, H0562 - 100-002 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 012	San Diego	Summary of Benefits, H0562 - 012 - English (PDF) Summary of Benefits, H0562 - 012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 009	San Francisco	Summary of Benefits, H0562 - 009 - English (PDF) Summary of Benefits, H0562 - 009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562 - 039	Yolo	Summary of Benefits, H0562 - 039 - English (PDF) Summary of Benefits, H0562 - 039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 084	Placer & Sacramento	Summary of Benefits, H0562 - 084 - English (PDF)
Health Net Seniority Plus Ruby (HMO)	H0562 - 079	Kern	Summary of Benefits, H0562 - 079 - English (PDF) Summary of Benefits, H0562 - 079 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 097	San Francisco	Summary of Benefits, H0562 - 097 - English (PDF) Summary of Benefits, H0562 - 097 - Spanish (PDF) Summary of Benefits, H0562 - 097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 112	Fresno	Summary of Benefits, H0562 - 112 - English (PDF) Summary of Benefits, H0562 - 112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 113	Alameda	Summary of Benefits, H0562 - 113 - English (PDF) Summary of Benefits, H0562 - 113 - Spanish (PDF) Summary of Benefits, H0562 - 113 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 103	Yolo	Summary of Benefits, H0562 - 103 - English (PDF) Summary of Benefits, H0562 - 103 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 119	Imperial	Summary of Benefits, H0562 - 119 - English (PDF) Summary of Benefits, H0562-119 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 120	Santa Clara & Stanislaus	Summary of Benefits, H0562 - 120 - English (PDF) Summary of Benefits, H0562 - 120 - Spanish (PDF)
Health Net Seniority Plus Sapphire (HMO)	H0562 - 122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara & Stanislaus	Summary of Benefits, H0562 - 122 - English (PDF) Summary of Benefits, H0562 - 122 - Spanish (PDF)
Health Net Seniority Plus Sapphire Premier (HMO)	H3561 - 002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare	Summary of Benefits, H3561 - 002 - English (PDF) Summary of Benefits, H3561 - 002 - Spanish (PDF) Summary of Benefits, H3561 - 002 - Chinese (PDF)
Health Net Seniority Plus Sapphire Premier (HMO)	H3561 - 004	Imperial, Riverside & San Bernardino	Summary of Benefits, H3561 - 004 - English (PDF) Summary of Benefits, H3561 - 004 - Spanish (PDF) Summary of Benefits, H3561 - 004 - Chinese (PDF)
Health Net Seniority Plus Sapphire Premier II (HMO)	H3561 - 005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare	Summary of Benefits, H3561 - 005 - English (PDF) Summary of Benefits, H3561 - 005 - Spanish (PDF) Summary of Benefits, H3561 - 005 - Chinese (PDF)
Health Net Seniority Plus Sapphire Premier II (HMO)	H3561 - 006	Imperial, Riverside & San Bernardino	Summary of Benefits, H3561 - 006 - English (PDF) Summary of Benefits, H3561 - 006 - Spanish (PDF) Summary of Benefits, H3561 - 006 - Chinese (PDF)

For HMO SNP Members
Plans	CMS#	County	Summary of Benefits
Health Net Seniority Plus Amber I (HMO D-SNP)	H0562 - 055	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Summary of Benefits, H0562 - 055 - English (PDF) Summary of Benefits, H0562 - 055 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 117	San Francisco	Summary of Benefits, H0562 - 117 - English (PDF) Summary of Benefits, H0562 - 117 - Spanish (PDF) Summary of Benefits, H0562 - 117 - Chinese (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 118	Fresno	Summary of Benefits, H0562 - 118 - English (PDF) Summary of Benefits, H0562 - 118 - Spanish (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane	Summary of Benefits, H0562 - 121 - English (PDF) Summary of Benefits, H0562 - 121 - Spanish (PDF)
Health Net Seniority Plus Amber II Premier (HMO D-SNP)	H3561 - 001	Fresno	Summary of Benefits, H3561 - 001 - English (PDF) Summary of Benefits, H3561 - 001 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 092	Kern, Los Angeles & Orange	Summary of Benefits, H0562 - 092 - English (PDF) Summary of Benefits, H0562 - 092 - Spanish (PDF) Summary of Benefits, H0562 - 092 - Chinese (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 114	San Diego	Summary of Benefits, H0562 - 114 - English (PDF) Summary of Benefits, H0562 - 114 - Spanish (PDF) Summary of Benefits, H0562 - 114 - Chinese (PDF)

For HMO Members

Plan	CMS#	County	Evidence of Coverage
Health Net Gold Select (HMO)	H0562 - 101-001	Los Angeles and Orange	Evidence of Coverage, H0562 - 101-001 - English (PDF) Evidence of Coverage, H0562 - 101-001 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562 - 101-002	Riverside & San Bernardino	Evidence of Coverage, H0562 - 101-002 - English (PDF) Evidence of Coverage, H0562 - 101-002 - Spanish (PDF)
Health Net Green (HMO)	H0562 - 044	Los Angeles, Riverside & San Bernardino	Evidence of Coverage, H0562 - 044 - English (PDF) Evidence of Coverage, H0562 - 044 - Spanish (PDF)
Health Net Green (HMO)	H0562 - 045	Alameda, Placer, Sacramento & Stanislaus	Evidence of Coverage, H0562 - 045 - English (PDF) Evidence of Coverage, H0562 - 045 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 068	Alameda & Stanislaus	Evidence of Coverage, H0562 - 068 - English (PDF) Evidence of Coverage, H0562 - 068 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 090	Fresno	Evidence of Coverage, H0562 - 090 - English (PDF) Evidence of Coverage, H0562 - 090 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-001	Los Angeles & Orange	Evidence of Coverage, H0562 - 100-001 - English (PDF) Evidence of Coverage, H0562 - 100-001 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-002	Riverside & San Bernardino	Evidence of Coverage, H0562 - 100-002 - English (PDF) Evidence of Coverage, H0562 - 100-002 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 012	San Diego	Evidence of Coverage, H0562 - 012 - English (PDF) Evidence of Coverage, H0562 - 012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 009	San Francisco	Evidence of Coverage, H0562 - 009 - English (PDF) Evidence of Coverage, H0562 - 009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562 - 039	Yolo	Evidence of Coverage, H0562 - 039 - English (PDF) Evidence of Coverage, H0562 - 039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 084	Placer, Sacramento	Evidence of Coverage, H0562 - 084 - English (PDF)
Health Net Ruby (HMO)	H0562 - 079	Kern	Evidence of Coverage, H0562 - 079 - English (PDF) Evidence of Coverage, H0562 - 079 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 097	San Francisco	Evidence of Coverage, H0562 - 097 - English (PDF) Evidence of Coverage, H0562 - 097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 112	Fresno	Evidence of Coverage, H0562 - 112 - English (PDF) Evidence of Coverage, H0562 - 112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 113	Alameda	Evidence of Coverage, H0562 - 113 - English (PDF) Evidence of Coverage, H0562 - 113 - Spanish (PDF) Evidence of Coverage, H0562 - 113 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 103	Yolo	Evidence of Coverage, H0562 - 103 - English (PDF) Evidence of Coverage, H0562 - 103 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 119	Imperial	Evidence of Coverage, H0562 - 119 - English (PDF) Evidence of Coverage, H0562 - 119 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 120	Santa Clara and Stanislaus	Evidence of Coverage, H0562 - 120 - English (PDF) Evidence of Coverage, H0562 - 120 - Spanish (PDF)
Health Net Seniority Plus Sapphire (HMO)	H0562 - 122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus	Evidence of Coverage, H0562 - 122 - English (PDF) Evidence of Coverage, H0562 - 122 - Spanish (PDF)
Health Net Senority Plus Sapphire Premier (HMO)	H3561 - 002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare	Evidence of Coverage, H3561 - 002 - English (PDF) Evidence of Coverage, H3561 - 002 - Spanish (PDF)
Health Net Senority Plus Sapphire Premier (HMO)	H3561 - 004	Imperial, Riverside & San Bernardino	Evidence of Coverage, H3561 - 004 - English (PDF) Evidence of Coverage, H3561 - 004 - Spanish (PDF)
Health Net Seniority Plus Sapphire Premier II (HMO)	H3561 - 005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco, Tulare	Evidence of Coverage, H3561 - 005 - English (PDF) Evidence of Coverage, H3561 - 005 - Spanish (PDF)
Health Net Seniority Plus Sapphire Premier II (HMO)	H3561 - 006	Imperial, Riverside & San Bernardino	Evidence of Coverage, H3561 - 006 - English (PDF) Evidence of Coverage, H3561 - 006 - Spanish (PDF)

For HMO SNP Members

2020 Medicare Defined Cost Sharing Amounts Notice (PDF)

Plans	CMS#	County	Evidence of Coverage
Health Net Amber I (HMO D-SNP)	H0562 - 055	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Evidence of Coverage, H0562 - 055 - English (PDF) Evidence of Coverage, H0562 - 055 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 117	San Francisco	Evidence of Coverage , H0562 - 117 - English (PDF) Evidence of Coverage , H0562 - 117 - Chinese (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 118	Fresno	Evidence of Coverage, H0562 - 118 - English (PDF) Evidence of Coverage, H0562 - 118 - Spanish (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulane	Evidence of Coverage, H0562 - 121 - English (PDF) Evidence of Coverage, H0562 - 121 - Spanish (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H3561 - 001	Fresno	Evidence of Coverage, H3561 - 001 - English (PDF) Evidence of Coverage, H3561 - 001 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 092	Kern, Los Angeles & Orange	Evidence of Coverage, H0562 - 092 - English (PDF) Evidence of Coverage, H0562 - 092 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 114	San Diego	Evidence of Coverage, H0562 - 114 - English (PDF) Evidence of Coverage, H0562 - 114 - Spanish (PDF)

For HMO Members

Plan	CMS#	County	Annual Notice of Changes
Health Net Gold Select (HMO)	H0562 - 101-001	Los Angeles, Orange	Annual Notice of Changes, H0562 - 101-001 - English (PDF) Annual Notice of Changes, H0562 - 101-001 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562 - 101-002	Riverside, San Bernardino	Annual Notice of Changes, H0562 - 101-002 - English (PDF) Annual Notice of Changes, H0562 - 101-002 - Spanish (PDF)
Health Net Green (HMO)	H0562 - 044	Los Angeles, Riverside & San Bernardino	Annual Notice of Changes, H0562 - 044 - English (PDF) Annual Notice of Changes, H0562 - 044 - Spanish (PDF)
Health Net Green (HMO)	H0562 - 045	Alameda, Placer, Sacramento & Stanislaus	Annual Notice of Changes, H0562 - 045 - English (PDF) Annual Notice of Changes, H0562 - 045 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 068	Alameda & Stanislaus	Annual Notice of Changes, H0562 - 068 - English (PDF) Annual Notice of Changes, H0562 - 068 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 090	Fresno	Annual Notice of Changes, H0562 - 090 - English (PDF) Annual Notice of Changes, H0562 - 090 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-001	Los Angeles, Orange	Annual Notice of Changes, H0562 - 100-001 - English (PDF) Annual Notice of Changes, H0562 - 100-001 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 100-002	Riverside & San Bernardino	Annual Notice of Changes, H0562 - 100-002 - English (PDF) Annual Notice of Changes, H0562 - 100-002 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 012	San Diego	Annual Notice of Changes, H0562 - 012 - English (PDF) Annual Notice of Changes, H0562 - 012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 009	San Francisco	Annual Notice of Changes, H0562 - 009 - English (PDF) Annual Notice of Changes, H0562 - 009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562 - 039	Yolo	Annual Notice of Changes, H0562 - 039 - English (PDF) Annual Notice of Changes, H0562 - 039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562 - 084	Placer, Sacramento	Annual Notice of Changes, H0562 - 084 - English (PDF)
Health Net Ruby (HMO)	H0562 - 079	Kern	Annual Notice of Changes, H0562 - 079 - English (PDF) Annual Notice of Changes, H0562 - 079 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 097	San Francisco	Annual Notice of Changes, H0562 - 097 - English (PDF) Annual Notice of Changes, H0562 - 097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 112	Fresno	Annual Notice of Changes, H0562 - 112 - English (PDF) Annual Notice of Changes, H0562 - 112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562 - 113	Alameda	Annual Notice of Changes, H0562 - 113 - English (PDF) Annual Notice of Changes, H0562 - 113 - Spanish (PDF) Annual Notice of Changes, H0562 - 113 - Chinese (PDF) Annual Notice of Changes, H0562 - 116-113 - English (PDF) Annual Notice of Changes, H0562 - 116-113 - Spanish (PDF) Annual Notice of Changes, H0562 - 116-113 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562 - 103	Yolo	Annual Notice of Changes, H0562 - 103 - English (PDF) Annual Notice of Changes, H0562 - 103< - Spanish (PDF)
Health Net Sapphire (HMO)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare.	Annual Notice of Changes, H0562 - 111-001-122 - English (PDF) Annual Notice of Changes, H0562 - 111-001-122 - Spanish (PDF) Annual Notice of Changes, H0562 - 111-002-122 - English (PDF) Annual Notice of Changes, H0562 - 111-002-122 - Spanish (PDF) Annual Notice of Changes, H0562 - 111-003-122 - English (PDF) Annual Notice of Changes, H0562 - 111-003-122 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561 - 002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare	Annual Notice of Changes, H3561 - 002 - English (PDF) Annual Notice of Changes, H3561 - 002 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561 - 004	Imperial, Riverside & San Bernardino	Annual Notice of Changes, H3561 - 004 - English (PDF) Annual Notice of Changes, H3561 - 004 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561 - 005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare	Annual Notice of Changes, H3561 - 005 - English (PDF) Annual Notice of Changes, H3561 - 005 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561 - 006	Imperial, Riverside & San Bernardino	Annual Notice of Changes, H3561 - 006 - English (PDF) Annual Notice of Changes, H3561 - 006 - Spanish (PDF)

For HMO SNP Members

Plan	CMS#	County	Annual Notice of Changes
Health Net Seniority Plus Amber I (HMO D-SNP)	H0562 - 055	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego & San Francisco and Tulare.	Annual Notice of Changes, H0562 - 055 - English (PDF) Annual Notice of Changes, H0562 - 055 - Spanish (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego & San Francisco and Tulare.	Annual Notice of Changes, H0562 - 110-001-121 - English (PDF) Annual Notice of Changes, H0562 - 110-001-121 - Spanish (PDF) Annual Notice of Changes, H0562 - 110-002-121 - English (PDF) Annual Notice of Changes, H0562 - 110-002-121 - Spanish (PDF) Annual Notice of Changes, H0562 - 110-003-121 - English (PDF) Annual Notice of Changes, H0562 - 110-003-121 - Spanish (PDF)
Health Net Seniority Plus Amber II Premier (HMO D-SNP)	H3561 - 001	Fresno	Annual Notice of Changes, H3561 - 001 - English (PDF) Annual Notice of Changes, H3561 - 001 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 092	Kern, Los Angeles & Orange	Annual Notice of Changes, H0562 - 092 - English (PDF) Annual Notice of Changes, H0562 - 092 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562 - 114	San Diego	Annual Notice of Changes, H0562 - 114 - English (PDF) Annual Notice of Changes, H0562 - 114 - Spanish (PDF)

Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

Plan	CMS #	County	Summary of Benefits
Health Net Healthy Heart (HMO)	H0562-009	San Francisco	Summary of Benefits, H0562-009 - English (PDF) Summary of Benefits, H0562-009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-012	San Diego	Summary of Benefits, H0562-012 - English (PDF) Summary of Benefits, H0562-012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-039	Yolo	Summary of Benefits, H0562-039 - English (PDF) Summary of Benefits, H0562-039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-068	Alameda & Stanislaus	Summary of Benefits, H0562-068 - English (PDF) Summary of Benefits, H0562-068 - Spanish (PDF)
Health Net Ruby (HMO)	H0562-079	Kern	Summary of Benefits, H0562-079 - English (PDF) Summary of Benefits, H0562-079 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-084	Placer, Sacramento	Summary of Benefits, H0562-084 - English (PDF)
Health Net Healthy Heart (HMO)	H0562-090	Fresno	Summary of Benefits, H0562-090 - English (PDF) Summary of Benefits, H0562-090 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-097	San Francisco	Summary of Benefits, H0562-097 - English (PDF) Summary of Benefits, H0562-097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562-103	Yolo	Summary of Benefits, H0562-103 - English (PDF) Summary of Benefits, H0562-103 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-112	Fresno	Summary of Benefits, H0562-112 - English (PDF) Summary of Benefits, H0562-112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-113	Alameda	Summary of Benefits, H0562-113 - English (PDF) Summary of Benefits, H0562-113 - Spanish (PDF) Summary of Benefits, H0562-113 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-119	Imperial	Summary of Benefits, H0562-119 - English (PDF) Summary of Benefits, H0562-119 - Spanish (PDF) Summary of Benefits, H0562-119- Chinese (PDF)
Health Net Ruby (HMO)	H0562-120	Santa Clara and Stanislaus	Summary of Benefits, H0562-120 - English (PDF) Summary of Benefits, H0562-120 - Spanish (PDF)
Health Net Seniority Plus Sapphire (HMO)	H0562-122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus	Summary of Benefits, H0562-122 - English (PDF) Summary of Benefits, H0562-122 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-123	Los Angeles, Orange, Riverside and San Bernardino counties	Summary of Benefits, H0562-123 - English (PDF) Summary of Benefits, H0562-123 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-124	Placer and Sacramento counties	Summary of Benefits, H0562-124 - English (PDF) Summary of Benefits, H0562-124 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562-125	Los Angeles and Orange counties	Summary of Benefits, H0562-125 - English (PDF) Summary of Benefits, H0562-125 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562-126	Riverside and San Bernardino counties	Summary of Benefits, H0562-126 - English (PDF) Summary of Benefits, H0562-126 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561-002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare	Summary of Benefits, H3561-002 - English (PDF) Summary of Benefits, H3561-002 - Spanish (PDF) Summary of Benefits, H3561-002 - Chinese (PDF)
Health Net Sapphire Premier (HMO)	H3561-004	Imperial, Riverside & San Bernardino	Summary of Benefits, H3561-004 - English (PDF) Summary of Benefits, H3561-004 - Spanish (PDF) Summary of Benefits, H3561-004 - Chinese (PDF)
Health Net Sapphire Premier II (HMO)	H3561-005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare	Summary of Benefits, H3561-005 - English (PDF) Summary of Benefits, H3561-005 - Spanish (PDF) Summary of Benefits, H3561-005 - Chinese (PDF)
Health Net Sapphire Premier II (HMO)	H3561-006	Imperial, Riverside, and San Bernardino	Summary of Benefits, H3561-006 - English (PDF) Summary of Benefits, H3561-006 - Chinese (PDF)
Health Net Green (HMO)	H0562-044	Alameda, Los Angeles, Placer, Riverside, Sacramento, San Bernardino and Stanislaus counties	Summary of Benefits, H0562-044 - English (PDF) Summary of Benefits, H0562-044 - Spanish (PDF)

Plans	CMS #	County	Summary of Benefits
Health Net Amber I (HMO D-SNP)	H0562-055	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Summary of Benefits, H0562-055 - English (PDF) Summary of Benefits, H0562-055 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562-092	Kern, Los Angeles & Orange	Summary of Benefits, H0562-092 - English (PDF) Summary of Benefits, H0562-092 - Spanish (PDF) Summary of Benefits, H0562-092 - Chinese (PDF)
Health Net Jade (HMO C-SNP)	H0562-114	San Diego	Summary of Benefits, H0562-114 - English (PDF) Summary of Benefits, H0562-114 - Spanish (PDF) Summary of Benefits, H0562-114 - Chinese (PDF)
Health Net Jade (HMO C-SNP)	H0562-118	Fresno and San Francisco	Summary of Benefits, H0562-118 - English (PDF) Summary of Benefits, H0562-118 - Spanish (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H0562-121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane	Summary of Benefits, H0562-121 - English (PDF) Summary of Benefits, H0562-121 - Spanish (PDF)
Health Net Seniority Plus Amber II Premier (HMO D-SNP)	H3561-001	Fresno and Sacramento	Summary of Benefits, H3561-001 - English (PDF) Summary of Benefits, H3561-001 - Spanish (PDF)

Plan	CMS #	County	Evidence Of Coverage
Health Net Healthy Heart (HMO)	H0562-009	San Francisco	Evidence Of Coverage H0562-009 - English (PDF) Evidence Of Coverage, H0562-009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-012	San Diego	Evidence Of Coverage, H0562-012 - English (PDF) Evidence Of Coverage, H0562-012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-039	Yolo	Evidence Of Coverage, H0562-039 - English (PDF) Evidence Of Coverage, H0562-039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-068	Alameda & Stanislaus	Evidence Of Coverage, H0562-068 - English (PDF) Evidence Of Coverage, H0562-068 - Spanish (PDF)
Health Net Ruby (HMO)	H0562-079	Kern	Evidence Of Coverage, H0562-079 - English (PDF) Evidence Of Coverage, H0562-079 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-084	Placer, Sacramento	Evidence Of Coverage, H0562-084 - English (PDF)
Health Net Healthy Heart (HMO)	H0562-090	Fresno	Evidence Of Coverage, H0562-090 - English (PDF) Evidence Of Coverage, H0562-090 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-097	San Francisco	Evidence Of Coverage, H0562-097 - English (PDF) Evidence Of Coverage, H0562-097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562-103	Yolo	Evidence Of Coverage, H0562-103 - English (PDF) Evidence Of Coverage, H0562-103 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-112	Fresno	Evidence Of Coverage, H0562-112 - English (PDF) Evidence Of Coverage, H0562-112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-113	Alameda	Evidence Of Coverage, H0562-113 - English (PDF) Evidence Of Coverage, H0562-113 - Spanish (PDF) Evidence Of Coverage, H0562-113 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-119	Imperial	Evidence Of Coverage H0562-119 - English (PDF) Evidence Of Coverage, H0562-119 - Spanish (PDF)
Health Net Ruby (HMO)	H0562-120	Santa Clara and Stanislaus	Evidence Of Coverage, H0562-120 - English (PDF) Evidence Of Coverage, H0562-120 - Spanish (PDF)
Health Net Seniority Plus Sapphire (HMO)	H0562-122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus	Evidence Of Coverage, H0562-122 - English (PDF) Evidence Of Coverage, H0562-122 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-123	Los Angeles, Orange, Riverside and San Bernardino counties	Evidence Of Coverage, H0562-123 - English (PDF) Evidence Of Coverage, H0562-123 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-124	Placer and Sacramento counties	Evidence Of Coverage, H0562-124 - English (PDF)
Health Net Gold Select (HMO)	H0562-125	Los Angeles and Orange counties	Evidence Of Coverage, H0562-125 - English (PDF) Evidence Of Coverage, H0562-125 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562-126	Riverside and San Bernardino counties	Evidence Of Coverage, H0562-126 - English (PDF) Evidence Of Coverage, H0562-126 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561-002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare	Evidence Of Coverage, H3561-002 - English (PDF) Evidence Of Coverage, H3561-002 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561-004	Imperial, Riverside & San Bernardino	Evidence Of Coverage, H3561-004 - English (PDF) Evidence Of Coverage, H3561-004 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561-005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare	Evidence Of Coverage, H3561-005 - English (PDF) Evidence Of Coverage, H3561-005 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561-006	Imperial, Riverside, and San Bernardino	Evidence Of Coverage, H3561-006 - English (PDF) Evidence Of Coverage, H3561-006 - Spanish (PDF)
Health Net Green (HMO)	H0562-044	Alameda, Los Angeles, Placer, Riverside, Sacramento, San Bernardino and Stanislaus counties	Evidence of Coverage, H0562-044 - English (PDF) Evidence of Coverage, H0562-044 - Spanish (PDF)

Plans	CMS #	County	Evidence of Coverage
Health Net Amber I (HMO D-SNP)	H0562-055	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Evidence Of Coverage, H0562-055 - English (PDF) Evidence Of Coverage, H0562-055 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562-092	Kern, Los Angeles & Orange	Evidence Of Coverage, H0562-092 - English (PDF) Evidence Of Coverage, H0562-092 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562-114	San Diego	Evidence Of Coverage, H0562-114 - English (PDF) Evidence Of Coverage, H0562-114 - Spanish (PDF)
Health Net Jade (HMO C-SNP)	H0562-118	Fresno and San Francisco	Evidence Of Coverage, H0562-118 - English (PDF) Evidence Of Coverage, H0562-118 - Spanish (PDF) Evidence Of Coverage, H0562-118 - Chinese (PDF)
Health Net Seniority Plus Amber II (HMO D-SNP)	H0562-121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane	Evidence Of Coverage, H0562-121 - English (PDF) Evidence Of Coverage, H0562-121 - Spanish (PDF)
Health Net Seniority Plus Amber II Premier (HMO D-SNP)	H3561-001	Fresno and Sacramento	Evidence Of Coverage, H3561-001 - English (PDF) Evidence Of Coverage, H3561-001 - Spanish (PDF)

Plan	CMS #	County	Annual Notice of Changes
Health Net Healthy Heart (HMO)	H0562-009	San Francisco	Annual Notice of Changes, H0562-009 - English (PDF) Annual Notice of Changes, H0562-009 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-012	San Diego	Annual Notice of Changes, H0562-012 - English (PDF) Annual Notice of Changes, H0562-012 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-039	Yolo	Annual Notice of Changes, H0562-039 - English (PDF) Annual Notice of Changes, H0562-039 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-044	Alameda, Los Angeles, Placer, Riverside, Sacramento, San Bernardino and Stanislaus counties	Annual Notice of Changes, H0562-044 - English (PDF) Annual Notice of Changes, H0562-044 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-045-044	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Annual Notice of Changes, H0562-045-044 - English (PDF) Annual Notice of Changes, H0562-045 -044 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-068	Alameda & Stanislaus	Annual Notice of Changes, H0562-068 - English (PDF) Annual Notice of Changes, H0562-068 - Spanish (PDF)
Health Net Ruby (HMO)	H0562-079	Kern	Annual Notice of Changes, H0562-079 - English (PDF) Annual Notice of Changes, H0562-079 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-084	Placer, Sacramento	Annual Notice of Changes, H0562-084 - English (PDF)
Health Net Healthy Heart (HMO)	H0562-090	Fresno	Annual Notice of Changes, H0562-090 - English (PDF) Annual Notice of Changes, H0562-090 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-097	San Francisco	Annual Notice of Changes, H0562-097 - English (PDF) Annual Notice of Changes, H0562-097 - Chinese (PDF)
Health Net Ruby Select (HMO)	H0562-103	Yolo	Annual Notice of Changes, H0562-103 - English (PDF) Annual Notice of Changes, H0562-103 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-112	Fresno	Annual Notice of Changes, H0562-112 - English (PDF) Annual Notice of Changes, H0562-112 - Spanish (PDF)
Health Net Ruby Select (HMO)	H0562-113	Alameda	Annual Notice of Changes, H0562-113 - English (PDF) Annual Notice of Changes, H0562-113 - Spanish (PDF) Annual Notice of Changes, H0562-113 - Chinese (PDF)
Health Net Healthy Heart (HMO)	H0562-119	Imperial	Annual Notice of Changes, H0562-119 - English (PDF) Annual Notice of Changes, H0562-119 - Spanish (PDF)
Health Net Ruby (HMO)	H0562-120	Santa Clara and Stanislaus	Annual Notice of Changes, H0562-120 - English (PDF) Annual Notice of Changes, H0562-120 - Spanish (PDF)
Health Net Seniority Plus Sapphire (HMO)	H0562-122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus	Annual Notice of Changes, H0562-122 - English (PDF) Annual Notice of Changes, H0562-122 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-100-001-123	Los Angeles, Orange, Riverside and San Bernardino counties	Annual Notice of Changes, H0562 -100-001-123 - English (PDF) Annual Notice of Changes, H0562 -100-001-123 - Spanish (PDF)
Health Net Healthy Heart (HMO)	H0562-100-002-123	Los Angeles, Orange, Riverside and San Bernardino counties	Annual Notice of Changes, H0562 -100-002-123 - English (PDF) Annual Notice of Changes, H0562 -100-002-123 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562-101-001-125	Los Angeles and Orange counties	Annual Notice of Changes, H0562 - 101-001-125- English (PDF) Annual Notice of Changes, H0562 - 101-001-125 - Spanish (PDF)
Health Net Gold Select (HMO)	H0562-101-002- 126	Riverside and San Bernardino counties	Annual Notice of Changes, H0562 - 101-002- 126 - English (PDF) Annual Notice of Changes, H0562 - 101-002- 126 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561-002	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare	Annual Notice of Changes, H3561-002 - English (PDF) Annual Notice of Changes, H3561-002 - Spanish (PDF)
Health Net Sapphire Premier (HMO)	H3561-004	Imperial, Riverside & San Bernardino	Annual Notice of Changes, H3561-004 - English (PDF) Annual Notice of Changes, H3561-004 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561-005	Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare	Annual Notice of Changes, H3561-005 - English (PDF) Annual Notice of Changes, H3561-005 - Spanish (PDF)
Health Net Sapphire Premier II (HMO)	H3561-006	Imperial, Riverside, and San Bernardino	Annual Notice of Changes, H3561-006 - English (PDF) Annual Notice of Changes, H3561-006 - Spanish (PDF)

Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

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For HMO SNP Members

For HMO Members

For HMO SNP Members

For HMO Members

For HMO SNP Members

Plan Benefit Materials

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For HMO Members

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Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members

For HMO SNP Members

Evidence Of Coverage (EOC)

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Annual Notice of Changes (ANOC)

For HMO Members

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Over-The-Counter Benefits

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Optional Benefit Individual Enrollment Form

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Newsletter

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members

For HMO SNP Members

Evidence Of Coverage (EOC)

For HMO Members

For HMO SNP Members

Annual Notice of Changes (ANOC)

For HMO Members

For HMO SNP Members

National Coverage

Dental

Optional Benefit Enrollment Form

Optional Supplemental Benefits Flyers

Over-The-Counter Benefits