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California Health Insurance: Health Net Gold 80 PPO

Health Net Gold 80 PPO

In-Network

Out-Network

Cost Share Information

Individual Deductible

$5,000

Family Deductible

$10,000

Out of Pocket Limit-Individual

$6,750

$25,000

Out of Pocket Limit-Family

$13,500

$50,000

Co-Insurance

20%

50%

Lifetime Maximum

Unlimited

Office Visits

Primary Care

$30

50% after deductible

Specialist

$55

50% after deductible

Adult Preventive Care

No Charge

Not Covered

Child Preventive Care

No Charge

Not Covered

Maternity Prenatal/Postnatal Care

No Charge

50% after deductible

Rehabilitation Services

$30

Not Covered

Chiropractic Care

Not Covered

Inpatient Services

Inpatient Hospital

20%

50% after deductible

Maternity Delivery/Inpatient

20%

50% after deductible

Outpatient Services

Outpatient Facility

20%

50% after deductible

Mental Health Outpatient

No charge

50% after deductible

Lab/X-Ray

$35/$55

50% after deductible

Emergency Care

Emergency Room

$325 (waived if admitted)

Paid as in-network

Urgent Care

$30

50% after deductible

Ambulance

$250

Paid as in-network

Prescription Drugs

Rx Deductible

N/A

Rx Generic

$15

Not covered

Rx Preferred

$55

Not covered

Rx Non-Preferred

$75

Not covered

Recovery/ Special Needs

Home Health Care

20%; 100 visits per year

Not covered

Durable Medical Equipment

20%

50% after deductible

Optional Benefits

None

Complete Benefit Summary

If you you have questions about the Health Net Gold 80 PPO plan or any other plans from Health Net of California please call The Lynn Company at (800)-326-5966 for more information on California Health Insurance Plans.

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