(844) 967-1917
Health Net Life Insurance Company

Platinum 90 Ambetter PPO

Plan Overview

Medical Deductable
  • Individual: $0
  • Family: $0
  • Per Person: $0
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $4,500
  • Family: $9,000
  • Per Person: $4,500

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non Preferred Brand Drugs
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Generic Drugs
  • CoPay: $5.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.

Emergency and Urgent Care

Emergency Room
  • CoPay: $150.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Urgent Care Facility
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision

Routine Eye Exams For Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Your actual effective date may be different from your requested effective date. Your actual effective date is subject to you meeting the regulatory requirements for a "Special Enrollment Qualifying Event." In order to qualify for a "Special Enrollment," you must show proof of your qualifying event
(e.g., if your qualifying event is a marriage, you must provide a copy of your marriage license, etc.). You must submit all supporting documentation WITH your application. Applications submitted without appropriate documentation cannot be processed. All documents (application and supporting documentation) must be submitted at the same time and through the same method (online application, envelope/email/fax). If supporting documentation is sent separate from the application there is no guarantee that it will be matched to the application.
Community Care HMO plans, offered by Health Net of California, are pending regulatory approval by the Department of Managed Health Care.
The premium rates quoted are subject to change.
HMO Coverage is provided by Health Net of California, Inc., PPO Insurance Plans are underwritten by Health Net Life Insurance Company.
Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net® is a registered trademark of Health Net, Inc.
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