Bronze 60 Ambetter HMO
Health Net of California, Inc
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $450
Family: $900
Per Person: $450
Combined medical and drug out of pocket maximum
Individual: $9800
Family: $19600
Per Person: $9800
Office visit
Primary Doctor
CoPay: $60.00
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: $95.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: The medical deductible does not apply to your first three specialty care office visits.
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
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: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
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: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
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: $60.00
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: 40.00% Coinsurance after deductible
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
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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.
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).
(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.