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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

Procedure Code

Procedure Description

C9050

EMAPALUMAB-LZSG

J0129

ABATACEPT INJECTION

J0178

AFLIBERCEPT INJECTION

J0584

BUROSUMAB-TWZA 1M

J0585

ONABOTULINUMTOXINA

J0604

CINACALCET, ESRD ON DIALYSIS

J0717

CERTOLIZUMAB PEGOL INJ 1MG

J0800

CORTICOTROPIN INJECTION

J0897

DENOSUMAB INJECTION

J1300

ECULIZUMAB INJECTION

J1428

ETEPLIRSEN, 10 MG

J1459

IVIG PRIVIGEN 500 MG

J1555

CUVITRU, 100 MG

J1556

IMM GLOB BIVIGAM, 500MG

J1557

GAMMAPLEX INJECTION

J1559

HIZENTRA INJECTION

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

HYQVIA 100MG IMMUNEGLOBULIN

J1599

IVIG NON-LYOPHILIZED, NOS

J1602

GOLIMUMAB FOR IV USE 1MG

J1745

INFLIXIMAB (REMICADE)

J1930

LANREOTIDE INJECTION

J2323

NATALIZUMAB INJECTION

J2350

OCRELIZUMAB, 1 MG

J2353

OCTREOTIDE INJECTION, DEPOT

J2357

OMALIZUMAB INJECTION

J2503

PEGAPTANIB SODIUM INJECTION

J2778

RANIBIZUMAB INJECTION

J3262

TOCILIZUMAB, 1 MG

J3304

TRIAMCINOLONE ACE XR 1MG

J3357

USTEKINUMAB SUB CU 1 MG

J3380

VEDOLIZUMAB

J3396

VERTEPORFIN INJECTION

J7189

FACTOR VIIA

J7318

DUROLANE 1 MG

J7320

GENVISC 850, 1MG

J7321

HYALGAN SUPARTZ VISCO-3 DOSE

J7322

HYMOVIS INJECTION 1 MG

J7323

EUFLEXXA INJ PER DOSE

J7324

ORTHOVISC INJ PER DOSE

J7325

SYNVISC OR SYNVISC-ONE

J7326

GEL-ONE

J7327

MONOVISC INJ PER DOSE

J7328

GELSYN-3 INJECTION 0.1 MG

J7329

TRIVISC 1 MG

J9022

ATEZOLIZUMAB,10 MG

J9145

INJECTION DARATUMUMAB 10 MG

J9173

DURVALUMAB, 10 MG

J9176

ELOTUZUMAB, 1MG

J9308

RAMUCIRUMAB

J9311

RITUXIMAB, HYALURONIDASE

J9355

TRASTUZUMAB INJECTION

Q2043

SIPULEUCEL-T AUTO CD54+

Q5103

INFLIXIMAB (INFLECTRA)

Q5104

INFLIXIMAB (RENFLEXIS)

 

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