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Health Net HMO 15 Plan Information

The HMO 15 plan from Health Net of California features the following:

Plan Type: HMO
Deductible: $1,000
In-Patient Hospital Co-Payment/Coinsurance: $1,000
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: Yes

Demarketed




HMO 15 Summary:

In Network Out of Network
Annual Deductible $1,000/calendar year for inpatient hospital services only Not Applicable
Annual Out-Of-Pocket Limit Individual: $3,000 Family: $6,000 Not Applicable
Lifetime Maximum Unlimited Unlimited
Office Visits
$15
Prescription Drugs $100 Ded then $15 Generic $25 Brand $50 Non-Formulary Not Applicable
Laboratory and Radiology No Charge Not Applicable
Annual Physical Exam $15 Not Applicable
Annual OB-GYN Exam $15 Not Applicable
Well Baby Care $15 Not Applicable
Outpatient Surgery $250 Not Applicable
Emergency Room $75 $75
Ambulance $50 Not Applicable
Home Health Care $15 (100 visits max/year) Not Applicable
Mental Health Services - Outpatient $15 Not Applicable
Chiropractic Care See Brochure for details Not Applicable
Acupuncture / Acupressure See Brochure for details Not Applicable
Inpatient Hospital $1,000 Deductible Only Covered for Emergencies
Maternity Care $1000 inpatient hospital services Deductible applies Not Applicable
Mental Health - Inpatient $1,000 Deductible Not Applicable
Chemical Dependency Not Covered Not Applicable

 

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.

 

 
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