Health Net California
HMO 40 NG Health Insurance Plan
A plan summary of the Health Net California HMO 40 NG Plan is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
$40 |
Not Applicable |
Office Visits |
$40 |
Not Applicable |
Annual Deductible |
Individual: $1,500 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 |
Not Applicable |
Prescription Drugs |
$100 Ded. then Generic: $15
Brand Formulary: $25
Non-Formulary: $50 |
Not Applicable |
Laboratory & X-Ray |
No Charge |
Not Applicable |
Annual Physical Exam |
No Charge |
Not Applicable |
Annual OB-GYN Exam |
No Charge |
Not Applicable |
Well Baby Care |
No Charge |
Not Applicable |
Outpatient Surgery |
$250 |
Not Applicable |
Emergency Room |
$100 (Waived if admitted) |
$100 |
Inpatient Hospital |
$1,500 inpatient hospital services deductible applies |
Only covered for Emergencies |
Ambulance |
$80 |
$80 |
Home Health Care |
$40 (See Brochure) |
Not Applicable |
Mental Health - Outpatient |
$40 |
Not Applicable |
Chiropractic Care |
See Brochure for Details |
Not Applicable |
Acupuncture |
See Brochure for Details |
Not Applicable |
Mental Health - Inpatient |
|
Not Applicable |
Chemical Dependency |
$100 per day (Detox Only) |
Not Applicable |
Maternity Care |
$1,500 inpatient hospital services deductible applies |
Not Applicable |
To learn more about your individual and family California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the health plan's underwriting guidelines.
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