Health Net Platinum 90 PureCare One EPO Plan Details for 2020- HealthPocket

Health Net Platinum 90 PureCare One EPO

$0.00/mo

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Zip Code90011
Applicant10/30/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameHealth Net Platinum 90 PureCare One EPO
Plan IDexch-CA2020HealthNetPlatinum90PureCareOneEPO
Plan Year2020
Insurance ProviderHealth Net
Metal LevelPlatinum EPO
Plan TypeEPO
Deductible$0
Out-of-Pocket Maximum$4,500
Plan Highlights

Yearly Deductible & Out-of-Pocket

Yearly Deductible - Individual$0
Yearly Deductible - Family$0
Separate Drug Deductible - Individual$0
Separate Drug Deductible - Family$0
Out-of-Pocket Max - Individual$4500
Out-of-Pocket Max - Family$9000
Maximum Cost per Prescription$250

Doctor Visit

Primary Care Visit$15 Copay
Specialist Visit$30 Copay
Other Practitioner Office Visit$15 Copay
Preventive Care/Screening/ImmunizationNo Charge

Tests

Laboratory Tests$15 Copay
X-rays and Diagnostic Imaging$30 Copay
Imaging (CT/PET Scans, MRIs)10% Coinsurance

Drugs

Tier 1 (Most Generic Drugs)$5 Copay
Tier 2 (Preferred Brand Drugs)$15 Copay
Tier 3 (Non-Preferred Brand Drugs)$25 Copay
Tier 4 (Specialty Drugs)10% Coinsurance

Outpatient Services

Outpatient Facility Fee10% Coinsurance
Outpatient Surgery Physician/Surgical Services10% Coinsurance
Outpatient Services Office Visits10% Coinsurance

ER & Urgent Care

Emergency Room Facility Fee$150 Copay
Emergency Transportation$150 Copay
Urgent Care$15 Copay
Emergency Room Professional FeeNo Charge

Hospital

Inpatient Hospital Services10% Coinsurance
Inpatient Physician and Surgical Services10% Coinsurance

Mental/Behavioral Health

Mental/Behavioral Health Outpatient Services$15 Copay
Mental/Behavioral Health Inpatient Facility Fee10% Coinsurance
Mental/Behavioral Health Inpatient Professional Fee10% Coinsurance
Substance Use Disorder Outpatient Services$15 Copay
Substance Use Disorder Inpatient Facility Fee10% Coinsurance
Substance Use Disorder Inpatient Professional Fee10% Coinsurance

Pregnancy

Prenatal CareNo Charge
Delivery and Maternity Care Inpatient Facility Fee10% Coinsurance
Delivery and Maternity Care Inpatient Professional Fee10% Coinsurance

Other Special Needs

Home Health Care Services10% Coinsurance
Outpatient Rehabilitation Services$15 Copay
Habilitation Services$15 Copay
Skilled Nursing Facility10% Coinsurance
Durable Medical Equipment10% Coinsurance
Hospice ServicesNo Charge
Acupuncture$15 Copay
Rehabilitative Speech Therapy$15 Copay
Rehabilitative Occupational and Rehabilitative Physical Therapy$15 Copay
Well Baby Visits and CareNo Charge
Allergy Testing$30 Copay
Diabetes EducationNo Charge
Nutritional CounselingNot covered

Children's Vision

Eye Exam for ChildrenNo Charge
Eyeglasses for ChildrenNo Charge

Children's Dental

Child Filling - One Surface20% Coinsurance
Child Dental CheckupNo Charge
Child Root Canal - Molar50% Coinsurance
Child Medically Necessary Orthodontia50% Coinsurance
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  • Phone Number
    (323) 918-2700
  • Office Locations
    4800 S Central Ave
    Los Angeles, CA 90011
4800 S Central Ave Los Angeles CA, 90011

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.