Health Net of California PPO ValueChoice 1500 Plan Information
Plan name: PPO ValueChoice 1500
Annual deductible: $1500 (Available to subscribers only)
Annual out-of-pocket maximum (preferred providers and non-preferred providers):
$4,000 combined in-network and out-of-network
Lifetime Maximum: $6 million
Visit to physician:
In-Network Provider: Covered in full after out-of-pocket maximum is met
Out-of-Network Provider: Covered in full after out-of-pocket maximum is met
X-ray and laboratory procedures:
In-Network Provider: Covered in full after out-of-pocket maximum is met
Out-of-Network Provider: Covered in full after out-of-pocket maximum is met
Annual Routine Physical Exams: Not Covered
Preventive care:
Adult preventive care (age 19 and older), Yearly OB/GYN exam (breast and pelvic exams, Pap smears and mammography)/Yearly Prostate cancer screening and exam:
In-Network Provider: 25%
Out-of-Network Provider: Not covered
Child preventive care (newborn to age 18); checkups,immunizations,vision and hearing exams:
In-Network Provider: 25%
Out-of-Network Provider: Not covered
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%
Outpatient Services:
Outpatient Surgery:
In-Network Provider: 25%
Out-of-Network Provider: 50%
Outpatient facility services:
In-Network Provider: 25%
Out-of-Network Provider: 50%
Hospitalization Services:
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%
Surgeon or assistant surgeon and anesthetic service (inpatient hospital setting):
In-Network Provider: 25%
Out-of-Network Provider: 50%
Reproductive health:
Sterilization:
In-Network Provider: 25%
Out-of-Network Provider: Not Covered
Other services:
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: Covered in full after out-of-pocket maximum is met
Out-of-Network Provider: Covered in full after out-of-pocket maximum is met
Chiropractic care (12-visti calendar year maximum/$20 maximum payable per visit): Not covered
Mental health services for nonsevere conditions:
In-Network Provider: 25% Inpatient / Covered in full after out-of-pocket maximum is met outpatient
Out-of-Network Provider: 50% inpatient / Not covered outpatient
Durable medical equipment (including foot orthotics):
In-Network Provider: 50% ($500 calendar year maximum)
Out-of-Network Provider: Not covered
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 level 1 (generic)
Out-of-Network Provider: Not Covered
Other Health Net of California health insurance plans:
