Health Net of California SimpleChoice 50 Plan Information
Plan name: SimpleChoice 50
Annual deductible (Family deductible is met when two family members meet their individual deductibles): $5000 (2 per family)
Annual out-of-pocket maximum:
Preferred providers: Each member must meet $5000 calendar year deductible only/ 2 per family
Non-preferred providers: $10,000/ 2 per family
Lifetime Maximum: $6 million
Visit to physician:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 50%
X-ray and laboratory procedures:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 50%
Annual Routine Physical Exams:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 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: $50 (Deductible waived)
Out-of-Network Provider: Not covered
Child preventive care (newborn to age 18); checkups,immunizations,vision and hearing exams:
In-Network Provider: $50 (Deductible waived)
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: Covered in full after deductible is met
Out-of-Network Provider: Covered in full after deductible is met
Urgent care center (facility charges):
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: Covered in full after deductible is met
Ambulance:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: Covered in full after deductible is met
Outpatient Services:
Outpatient Surgery:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 50%
Outpatient facility services:
In-Network Provider: Covered in full after deductible is met
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: Covered in full after deductible is met
Out-of-Network Provider: 50%
Surgeon or assistant surgeon and anesthetic service (inpatient hospital setting):
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 50%
Reproductive health:
Sterilization:
In-Network Provider: Covered in full after deductible is met
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 deductible is met
Out-of-Network Provider: Not covered
Chiropractic care (12-visti calendar year maximum/$20 maximum payable per visit):
In-Network Provider: 50%
Out-of-Network Provider: Not covered
Mental health services for nonsevere conditions:
In-Network Provider: Covered in full after deductible is met
Out-of-Network Provider: 50% inpatient / Not covered outpatient
Durable medical equipment (including foot orthotics):
In-Network Provider: Covered in full after deductible is met
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: $250 brand deductible, $5 level 1 (generic), $35 level 2 (brand), $50 Level 3 (non formulary)
Out-of-Network Provider: Not Covered
Other Health Net of California health insurance plans:
