PureCare One EPO is available through Covered CA in Contra Costa, Marin, Merced, Napa, San Francisco, San Joaquin, San Mateo, Santa Cruz, Solano, Sonoma, Stanislaus, and Tulare counties.

Plan Overview

Health Net Bronze 60 EPO

California Individual & Family Plans
Available through Covered California™
Health Net Life Insurance Company (Health Net)

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT AND EVIDENCE OF COVERAGE (EOC) SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

The copayment amounts listed below are the fees charged to you for covered services you receive. Copayments can be either a fixed dollar amount or a percentage of Health Net’s cost for the service or supply and is agreed to in advance by Health Net and the contracted provider. Fixed dollar copayments are due and payable at the time services are rendered. Percentage copayments are usually billed after the service is received.

Benefit description

Member(s) responsibility1

Unlimited lifetime maximum. Benefits are subject to a deductible unless noted.

Plan maximums
Calendar year deductible

$6,300 single / $12,600 family

Out-of-pocket maximum2 (Includes calendar year deductible. Payments for services and supplies not covered by this plan will not be applied to this calendar year out-of-pocket maximum.)

$6,800 single / $13,600 family

Professional services
Office visit copay

Visits 1–3: $75 (deductible waived) Visits 4+: $75 (deductible applies)3

Specialist visit

Visits 1–3: $105(deductible waived) Visits 4+: $105 (deductible applies)3

Other practitioner office visit (including medically necessary acupuncture)

Visits 1–3: $75 (deductible waived) Visits 4+: $75 (deductible applies)3

Preventive care services4

$0 (deductible waived)

X-ray and diagnostic imaging5

100%

Laboratory tests

$40 (deductible waived)

Imaging (CT/PET scans, MRIs)5

100%

Rehabilitation and habilitation therapy

$75 (deductible waived)

Outpatient services
Outpatient surgery (includes facility fee and physician/surgeon fees)
5

100%

Hospital services
Inpatient hospital facility (includes maternity)
5

100%

Skilled nursing care5

100%

Emergency services
Emergency room services (copays waived if admitted)

100% facility / $0 physician (deductible waived)

Urgent care

Visits 1–3: $75 (deductible waived) Visits 4+: $75 (deductible applies)3

Ambulance services (ground and air)5

100%

Mental/Behavioral Health/Substance use disorder services
Mental/Behavioral health/Substance use disorder (inpatient)
5

100%

Mental/Behavioral health/Substance use disorder (outpatient)

Office visit: $75 (deductible waived)Other than office visit: $0 (deductible waived)

Home health care services (100 visits per calendar year)5

100%

Other services
Durable medical equipment
5

100%

Hospice service

$0 (deductible waived)

Self-injectables (other than insulin)6,7

100% up to $500/30-day script (after Rx deductible)

Prescription drug coverage
Brand-name calendar year deductible
Prescription drugs (up to a 30-day supply obtained through a participating pharmacy)
7

$500 single / $1,000 family

Tier I (most generics and low-cost preferred brands)6

100% up to $500/30-day script (after Rx deductible)

Tier II (non-preferred generics and preferred brands)6

100% up to $500/30-day script (after Rx deductible)

Tier III (non-preferred brands only)6

100% up to $500/30-day script (after Rx deductible)

Tier IV (Specialty drugs)6

100% up to $500/30-day script (after Rx deductible)

Pediatric dental8,9 Diagnostic and preventive services

$0 (deductible waived)

Pediatric vision8,10 Routine eye exam

$0 (deductible waived)

Glasses (limitations apply)

1 pair per year (deductible waived)

This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Policy for terms and conditions of coverage.

1In accordance with the Affordable Care Act, American Indians and Alaskan Natives, as determined eligible by the Exchange and regardless of income, have no cost- sharing obligation under this Policy for items or services that are Essential Health Benefits if the items or services are provided by a provider of the Indian Health Service (IHS), an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services, as defined by federal law. Cost- sharing means copayments, including coinsurance and deductibles.

2Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers.

3Visits 1–3 (combined between office visits, specialist office visit, urgent care, prenatal and postnatal visits, acupuncture, outpatient mental health/substance abuse): The calendar year deductible is waived. Visits 4–unlimited: The calendar year deductible applies.

4Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services.

5After the medical deductible has been reached, the member is responsible for 100% of the eligible charges until their out-of-pocket maximum limit is met.

6After the pharmacy deductible has been reached, the member will be responsible for 100% of the cost of all Tier 1, 2, 3, and 4 drugs up to a maximum payment of $500 for each prescription of up to a 30-day supply, until the out-of-pocket maximum limit is met.

7The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the Policy for complete information on prescription drugs. Plans will cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your Policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The Policy is a legal, binding document. If the information in this brochure differs from the information in the Policy, the Policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.healthnet.com.

8Pediatric dental and vision are included on all plans.

9The pediatric dental benefits are underwritten by Health Net Life Insurance Company and administered by Dental Benefit Providers, Inc., dba Dental Benefit

Administrative Services (DBP Entities). DBP entities are not affiliated with Health Net. See policy for pediatric dental benefit details.

10The pediatric vision services benefits are underwritten by Health Net Life Insurance Company. Health Net contracts with EyeMed Vision Care, LLC, a vision services provider panel, to administer the pediatric vision services benefits.

Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Health Net:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).
  • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Health Net’s Customer Contact Center at 1-888-926-4988 (TTY: 711).

If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a grievance by mail: Health Net of California, Inc., PO Box 10348, Van Nuys, California 91410-0348, by fax: 1-877-831-6019, or online: healthnet.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or
by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Health Net EPO insurance plans, Policy Form # P34401, are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. Covered California is a registered trademark of the State of California. All rights reserved.

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