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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
Health Net
Gold Select (HMO)
H0562 - 101-002
  • Riverside & San Bernardino 
Health Net
Seniority Plus Green (HMO)
H0562 - 044
 
  • Los Angeles, Riverside & San Bernardino
Health Net
Seniority Plus Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Health Net
Healthy Heart (HMO)
H0562 - 068
  • Alameda & Stanislaus
Health Net
Healthy Heart (HMO)
H0562 - 090
  • Fresno
Health Net
Healthy Heart (HMO)
H0562 - 100-001
  • Los Angeles & Orange
Health Net
Healthy Heart (HMO)
H0562 - 100-002
  • Riverside & San Bernardino
Health Net
Healthy Heart (HMO)
H0562 - 012
  • San Diego
Health Net
Healthy Heart (HMO)
H0562 - 009
  • San Francisco
Health Net
Healthy Heart (HMO)
H0562 - 039
  • Yolo
Health Net
Healthy Heart (HMO)
H0562 - 084
  • Placer & Sacramento
Health Net
Seniority Plus Ruby (HMO)
H0562 - 079
  • Kern 
Health Net
Ruby Select (HMO)
H0562 - 097
  • San Francisco
Health Net
Ruby Select (HMO)
H0562 - 112
  • Fresno
Health Net
Ruby Select (HMO)
H0562 - 113
  • Alameda
Health Net
Ruby Select (HMO)
H0562 - 103
  • Yolo
Health Net
Healthy Heart (HMO)
H0562 - 119
  • Imperial
Health Net
Healthy Heart (HMO)
H0562 - 120
  • Santa Clara & Stanislaus
Health Net
Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara & Stanislaus
Health Net
Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Health Net
Seniority Plus Sapphire Premier (HMO)
H3561 - 004
  • Imperial, Riverside & San Bernardino
Health Net
Seniority Plus Sapphire Premier II (HMO)
H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Health Net
Seniority Plus Sapphire Premier II (HMO)
H3561 - 006
  • Imperial, Riverside & San Bernardino

 

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
Health Net
Jade (HMO C-SNP) 
H0562 - 117
  • San Francisco

 

Health Net
Jade (HMO C-SNP) 
H0562 - 118
  • Fresno
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
Health Net
Seniority Plus Amber II Premier (HMO D-SNP) 
H3561 - 001
  • Fresno
Health Net
Jade (HMO C-SNP)
H0562 - 092
  • Kern, Los Angeles & Orange
Health Net
Jade (HMO C-SNP)
H0562 - 114
  • San Diego

For HMO Members

Plan CMS# County Evidence of Coverage
Health Net
Gold Select (HMO)
H0562 - 101-001
  • Los Angeles and Orange
Health Net
Gold Select (HMO)
H0562 - 101-002
  • Riverside & San Bernardino 
Health Net
Green (HMO)
H0562 - 044

 

  • Los Angeles, Riverside & San Bernardino
Health Net
Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Health Net
Healthy Heart (HMO)
H0562 - 068
  • Alameda & Stanislaus
Health Net
Healthy Heart (HMO)
H0562 - 090
  • Fresno
Health Net
Healthy Heart (HMO)
H0562 - 100-001
  • Los Angeles & Orange
Health Net
Healthy Heart (HMO)
H0562 - 100-002
  • Riverside & San Bernardino
Health Net
Healthy Heart (HMO)
H0562 - 012
  • San Diego
Health Net
Healthy Heart (HMO)
H0562 - 009
  • San Francisco
Health Net
Healthy Heart (HMO)
H0562 - 039
  • Yolo
Health Net
Healthy Heart (HMO)
H0562 - 084
  • Placer, Sacramento
Health Net
Ruby (HMO)
H0562 - 079
  • Kern 
Health Net
Ruby Select (HMO)
H0562 - 097
  • San Francisco
Health Net
Ruby Select (HMO)
H0562 - 112
  • Fresno
Health Net
Ruby Select (HMO)
H0562 - 113
  • Alameda
Health Net
Ruby Select (HMO)
H0562 - 103
  • Yolo
Health Net
Healthy Heart (HMO)

H0562 - 119

 

  • Imperial
Health Net
Healthy Heart (HMO)
H0562 - 120
  • Santa Clara and Stanislaus
Health Net Seniority Plus Sapphire (HMO) H0562 - 122
  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Health Net Senority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Health Net Senority Plus Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Health Net Seniority Plus Sapphire Premier II (HMO)

H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco, Tulare
Health Net Seniority Plus Sapphire Premier II (HMO)

H3561 - 006
  • Imperial, Riverside & San Bernardino

 

For HMO SNP Members

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
Health Net
Jade (HMO C-SNP) 
H0562 - 117
  • San Francisco

 

Health Net
Jade (HMO C-SNP) 
H0562 - 118 
  • Fresno
Health Net
Seniority Plus Amber II (HMO D-SNP) 
H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulane
Health Net
Seniority Plus Amber II (HMO D-SNP) 
H3561 - 001 
  • Fresno
Health Net
Jade (HMO C-SNP)
H0562 - 092 
  • Kern, Los Angeles & Orange
Health Net
Jade (HMO C-SNP)
H0562 - 114 
  • San Diego



For HMO Members

Plan CMS# County Annual Notice of Changes
Health Net Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange
Health Net Gold Select (HMO) H0562 - 101-002
  • Riverside, San Bernardino 
Health Net Green (HMO)

H0562 - 044

 


  • Los Angeles, Riverside & San Bernardino
Health Net Green (HMO)

H0562 - 045

  • Alameda, Placer, Sacramento & Stanislaus
Health Net Healthy Heart (HMO)

H0562 - 068

 

  • Alameda & Stanislaus
Health Net Healthy Heart (HMO) H0562 - 090
  • Fresno
Health Net Healthy Heart (HMO)
H0562 - 100-001
  • Los Angeles, Orange
Health Net Healthy Heart (HMO) H0562 - 100-002
  • Riverside & San Bernardino
Health Net Healthy Heart (HMO) H0562 - 012
  • San Diego
Health Net Healthy Heart (HMO) H0562 - 009
  • San Francisco
Health Net Healthy Heart (HMO) H0562 - 039
  • Yolo
Health Net Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Health Net Ruby (HMO)

H0562 - 079

 

  • Kern 
Health Net Ruby Select (HMO)

H0562 - 097

 

  • San Francisco
Health Net Ruby Select (HMO) H0562 - 112
  • Fresno
Health Net Ruby Select (HMO) H0562 - 113
  • Alameda
Health Net Ruby Select (HMO)

H0562 - 103

  • Yolo
Health Net Sapphire (HMO) H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare.
Health Net Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Health Net Sapphire Premier (HMO)

H3561 - 004

  • Imperial, Riverside & San Bernardino
Health Net Sapphire Premier II (HMO)

H3561 - 005

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Health Net Sapphire Premier II (HMO)

H3561 - 006

  • Imperial, Riverside & San Bernardino

 

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.
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.
Health Net Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Health Net Jade (HMO C-SNP)

H0562 - 092

 

  • Kern, Los Angeles & Orange
Health Net Jade (HMO C-SNP)

H0562 - 114

  • San Diego

For HMO Members

Plan CMS# County Low Income Subsidy
Health Net
Gold Select (HMO)
H0562 - 101-001
  • Los Angeles & Orange
Health Net
Gold Select (HMO)
H0562 - 101-002
  • Riverside, San Bernardino 
Health Net
Healthy Heart (HMO)
H0562 - 068
  • Alameda & Stanislaus
Health Net
Healthy Heart (HMO)
H0562 - 090
  • Fresno
Health Net
Healthy Heart (HMO)
H0562 - 100-001
  • Los Angeles & Orange
Health Net
Healthy Heart (HMO)
H0562 - 100-002
  • Riverside & San Bernardino
Health Net
Healthy Heart (HMO)
H0562 - 012
  • San Diego
Health Net
Healthy Heart (HMO)
H0562 - 009
  • San Francisco
Health Net
Healthy Heart (HMO)
H0562 - 039
  • Yolo
Health Net
Healthy Heart (HMO)
H0562 - 084
  • Placer, Sacramento
Health Net
Seniority Plus Ruby (HMO)
H0562 - 079
  • Kern 
Health Net
Ruby Select (HMO)
H0562 - 097
  • San Francisco
Health Net
Ruby Select (HMO)
H0562 - 112
  • Fresno
Health Net
Ruby Select (HMO)
H0562 - 113
  • Alameda
Health Net
Ruby Select (HMO)
H0562 - 103
  • Yolo
Health Net
Healthy Heart (HMO)
H0562 - 119
  • Imperial
Health Net
Healthy Heart (HMO)
H0562 - 120
  • Santa Clara and Stanislaus
Health Net
Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Health Net
Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare
Health Net
Seniority Plus Sapphire Premier (HMO)
H3561 - 004
  • Imperial, Riverside & San Bernardino
Health Net
Seniority Plus Sapphire Premier II (HMO)
H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare
Health Net
Seniority Plus Sapphire Premier II (HMO)
H3561 - 006
  • Imperial, Riverside, and San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Low Income Subsidy
Health Net
Seniority Plus Amber I (HMO D-SNP)
H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Health Net
Jade (HMO C-SNP) 
H0562 - 117
  • San Francisco

 

Health Net
Jade (HMO C-SNP) 
H0562 - 118
  • Fresno
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
Health Net
Seniority Plus Amber II Premier (HMO D-SNP) 
H3561 - 001
  • Fresno
Health Net
Jade (HMO C-SNP)
H0562 - 092
  • Kern, Los Angeles & Orange
Health Net
Jade (HMO C-SNP)
H0562 - 114
  • San Diego

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.

For HMO Members

Plan CMS# County Extra Benefits Brochure
Health Net Gold Select (HMO) H0562 - 101-001
  • Los Angeles & Orange
Health Net Gold Select (HMO) H0562 - 101-002
  • Riverside & San Bernardino 
Health Net Seniority Plus Green (HMO) H0562 - 044
 
  • Los Angeles, Riverside & San Bernardino
Health Net Seniority Plus Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Health Net Healthy Heart (HMO) H0562 - 068
  • Alameda & Stanislaus
Health Net Healthy Heart (HMO) H0562 - 090
  • Fresno
Health Net Healthy Heart (HMO) H0562 - 100-001
  • Los Angeles & Orange
Health Net Healthy Heart (HMO) H0562 - 100-002
  • Riverside & San Bernardino
Health Net Healthy Heart (HMO) H0562 - 012
  • San Diego
Health Net Healthy Heart (HMO) H0562 - 009
  • San Francisco
Health Net Healthy Heart (HMO) H0562 - 039
  • Yolo
Health Net Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Health Net Seniority Plus Health Net Ruby (HMO) H0562 - 079
  • Kern 
Health Net Ruby Select (HMO) H0562 - 097
  • San Francisco
Health Net Ruby Select (HMO) H0562 - 112
  • Fresno
Health Net Ruby Select (HMO) H0562 - 113
  • Alameda
Health Net Ruby Select (HMO) H0562 - 103
  • Yolo
Health Net Healthy Heart (HMO) H0562 - 119
  • Imperial
Health Net Healthy Heart (HMO) H0562 - 120
  • Santa Clara and Stanislaus
Health Net Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Health Net Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare
Health Net Seniority Plus Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Health Net Seniority Plus Sapphire Premier II (HMO) H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare
Health Net Seniority Plus Sapphire Premier II (HMO) H3561 - 006
  • Imperial, Riverside, and San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Extra Benefits Brochure
Health Net Seniority Plus Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Health Net Jade (HMO C-SNP)  H0562 - 117
  • San Francisco

 

Health Net Jade (HMO C-SNP)  H0562 - 118
  • Fresno
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
Health Net Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Health Net Jade (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles & Orange
Health Net Jade (HMO C-SNP) H0562 - 114
  • San Diego

 

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