Health Net of California FirstChoice PPO Plan Information
Plan name: FirstChoice PPO
Annual deductible:
Per Member:$3,000
Per Family: 2 per family
Annual FirstChoice Dollars: FirstChoice PPO gives you First Dollar coverage for the first $500 of covered expenses per person per calendar year before you pay copayments, coinsurance or deductibles.
Once this $500 is met, coverage is reimbursed for In-Network providers at 70% of covered expenses after you meet your annual deductible. The First Dollar benefit does not apply to prescription drug benefits.
In-Network Provider: $500
Out-of-Network Provider: N/A
Annual out-of-pocket maximum:
In-Network Provider: (Individual) $3,750 (includes deductible)
Out-of-Network Provider: (Individual) $10,000 (includes deductible)
Family: 2 per family (includes deductible)
Lifetime Maximum: $6 million
Visit to physician:
In-Network Provider: 30%
Out-of-Network Provider: 50%
X-ray and laboratory procedures:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Preventive Care:
Routine physical exams, including routine lab and X-ray services:
In-Network Provider: $20 copay + 30%
Out-of-Network Provider: Not Covered
Annual OB/GYN exam (breast and pelvic exams, cervical cancer screening and mammography):
In-Network Provider:$20 copay + 30%
Out-of-Network Provider: Not covered
Immunizations Standard:
In-Network Provider: $20 copay + 30%
Out-of-Network Provider: Not Covered
To meet foreign travel or occupational requirements:
In-Network Provider:30%
Out-of-Network Provider: 50%
Child preventive care (newborn to age 18); checkups,vision and hearing exams:
In-Network Provider: $20 copay + 30%
Out-of-Network Provider: Not covered
Child preventive care immunizations:
In-Network Provider: $20 copay + 30%
Out-of-Network Provider: Not covered
Allergy testing and injection services:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Maternity and pregnancy (Prenatal and postnatal office visits): Not covered
Maternity care in hospital: Not covered
Emergency and urgent care:
Emergency room (professional and facility charges):
In-Network Provider: 30%
Out-of-Network Provider: 30%
Deductible if not admitted to inpatient facility: $80 (Calendar year deductible applies)
Urgent care center (facility charges):
In-Network Provider: 30%
Out-of-Network Provider: 30%
Deductible if not admitted to inpatient facility: $40 (Calendar year deductible applies)
Ambulance:
In-Network Provider: 30%
Out-of-Network Provider: 30%
Inpatient Hospital services (non-emergency care):
Physician/surgeon and anesthetics services:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Organ and bone marrow transplants (nonexperimental and noninvestigational):
In-Network Provider: 30%
Out-of-Network Provider: Not covered
Alcohol detoxification:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Hospital and skilled nursing facility (facility charges):
Inpatient, semiprivate hospital room or intensive care unit with ancillary services (unlimited,except for mental health and substance abuse treatment):
In-Network Provider: 30% ($250 Per Admission Copay)
Out-of-Network Provider: 50% ($250 Per Admission Copay)
Outpatient Surgery:
In-Network Provider: 30% ($250 copay)
Out-of-Network Provider: 50% ($250 copay)
Skilled nursing facility:
In-Network Provider: 30% (100-day annual limit combined in- and out-of-network)
Out-of-Network Provider: 50% (100-day annual limit combined in- and out-of-network)
Reproductive health:
Sterilization:
In-Network Provider: 30%
Out-of-Network Provider: Not Covered
Other services:
Home health services:
In-Network Provider: 30% (Limited to 90 visits per calendar year combines in-and out-of-network)
Out-of-Network Provider: 50% ($75 maximum payable per day),(Limited to 90 visits per calendar year combines in-and out-of-network)
Hospice services:
In-Network Provider: 30% (Limited to 90 visits per calendar year combines in-and out-of-network)
Out-of-Network Provider: 50% ($25 maximum payable per visit), (Limited to 90 visits per calendar year combines in-and out-of-network)
Rehabilitative therapy (includes physical, speech,
occupational, respiratory and cardiac therapy) Limited to 20 visits per calendar year combined in- and out-ofnetwork:
In-Network Provider: 30% (Limited to 90 visits per calendar year combines in-and out-of-network)
Out-of-Network Provider: 50% ($25 maximum payable per visit), (Limited to 90 visits per calendar year combines in-and out-of-network)
Chiropractic care (12-visit calendar year maximum/$20 maximum payable per visit):
In-Network Provider: Not covered
Out-of-Network Provider: Not covered
Acupuncture:
In-Network Provider: Not covered
Out-of-Network Provider: Not covered
Mental health services for severe conditions:
In-Network Provider: $250 Per Admission Copay plus 30% Inpatient/30% OUtpatient
Out-of-Network Provider: $250 Per Admission Copay plus 50% Inpatient/50% OUtpatient
Mental health services for nonsevere conditions:
In-Network Provider: $250 Per Admission Copay plus 30% Inpatient/30% OUtpatient
Out-of-Network Provider: $250 Per Admission Copay plus 50% Inpatient/50% OUtpatient
Durable medical equipment (including foot orthotics):
In-Network Provider: 50% ($2000 maximum payable per calendar year)
Out-of-Network Provider: Not covered
Corrective footwear:
In-Network Provider: 50% ($200 maximum payable per calendar year)
Out-of-Network Provider: Not covered
Prosthetics and corrective appliances:
In-Network Provider: 30%
Out-of-Network Provider: 50%
Outpatient prescription drugs:
Filled at participating pharmacy (up to a 30-day supply); not covered at non-participating pharmacies: Not covered
Filled through mail order (up to a 90-day supply):
In-Network Provider: $15 copay (generic only)
Out-of-Network Provider: Not Covered
Other Health Net of California health insurance plans:
