Health Net of California Net Saver 1500 Plan Information
Plan name: Net Saver 1500
Annual deductible:
Annual deductible is met when two family members meet their individual deductibles: $1,500
Annual out-of-pocket maximum (family maximum is twice this amount):
$4,000 combined in-network and out-of-network (includes deductible)
Lifetime Maximum: $6 million
Visit to physician:
In-Network Provider:Negotiated fee until OOPM is met, then covered in full
Out-of-Network Provider: No benefits until OOPM is met, then covered in full
X-ray and laboratory procedures:
In-Network Provider:Negotiated fee until OOPM is met, then covered in full
Out-of-Network Provider:No benefits until OOPM is met, then covered in full
Preventive care:
Routine physical exams,including routine lab and X-ray services:
In-Network Provider: Not covered
Out-of-NetworkProvider:Not covered
Annual OB/GYN exam (breast and pelvic exams,cervical cancer screening and mammography):
In-Network Provider: 25%
Out-of-Network Provider: Not covered
Prostate cancer screening and exam:
In-Network Provider: 25%
Out-of-Network Provider: Not covered
Immunizations Standard: Not covered
To meet foreign travel or occupational requirements: Not covered
Child preventive care (newborn to age 18); checkups,vision and hearing exams, Immunizations:
In-Network Provider: 25%
Out-of-Network Provider: Not covered
Child preventive care Immunizations:
In-Network Provider:25%
Out-of-Network Provider: Not covered
Allergy testing and injection services:
In-Network Provider: Negotiated fee until OOPM is met, then covered in full
Out-of-Network Provider:No benefits until OOPM is met, then covered in full
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: 25%
Out-of-Network Provider: 25%
Urgent care center (facility charges):
In-Network Provider: 25%
Out-of-Network Provider: 25%
Ambulance:
In-Network Provider: 25%
Out-of-Network Provider: 25%
Inpatient Hospital services (non-emergency care):
Physician/surgeon and anesthetics services:
In-Network Provider: 25%
Out-of-Network Provider: 50%
Organ and bone marrow transplants (nonexperimental and noninvestigational):
In-Network Provider: 25%
Out-of-Network Provider: Not covered
Alcohol detoxification (3 days per calendar year combined in-and-out-ofnetwork):
In-Network Provider: 25
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: 25%
Out-of-Network Provider: 50%
Outpatient surgery:
In-Network Provider: 25%
Out-of-Network Provider: 50%
Skilled nursing facility (100-day annual limit combined in- and out-of-network):
In-Network Provider: 25%
Out-of-Network Provider: 50%
Reproductive health:
Sterilization:
In-Network Provider: 25%
Out-of-Network Provider: Not Covered
Other services:
Home health services (limited to 60 visits per calendar year combined in- and out-of network):
In-Network Provider: 25%
Out-of-Network Provider: 50% ($75 maximum payable per day)
Hospice services:
In-Network Provider: 25%
Out-of-Network Provider: 50%
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:Negotiated fee until OOPM is met, then covered in full
Out-of-Network Provider: No benefits until OOPM is met, then covered in full
Chiropractic care: Not covered
Acupuncture: Not covered
Mental health services for severe conditions:
In-Network Provider: 25% Inpatient / Negotiated fee until OOPM is met Outpatient then covered in full
Out-of-Network Provider: 50% inpatient5 / No benefits until OOPM is met then covered in full Outpatient
Mental health services for nonsevere conditions:
In-Network Provider: 25% Inpatient / Negotiated fee until OOPM is met Outpatient then covered in full
Out-of-Network Provider: 50% inpatient/ not covered outpatient
Durable medical equipment (including foot orthotics):
In-Network Provider: 50%
Out-of-Network Provider: Not covered
Corrective footwear($200 maximum payable per calendar year):
In-Network Provider:50%
Out-of-Network Provider: Not covered
Prosthetics and corrective appliances:
In-Network Provider: 25%
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): Not covered
Other Health Net of California health insurance plans:
