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 Gold 80 EPO

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


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.

Plan maximums
Calendar year deductible


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

$6,750 single / $13,500 family

Professional services
Office visit copay


Specialist visit


Other practitioner office visit (including medically necessary acupuncture)


Preventive care services3


X-ray and diagnostic imaging


Laboratory tests


Imaging (CT/PET scans, MRIs)


Rehabilitation and habilitation therapy


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


Hospital services
Inpatient hospital facility (includes maternity)


Skilled nursing care


Emergency services
Emergency room services (copays waived if admitted)

$325 facility / $0 physician

Urgent care


Ambulance services (ground and air)


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


Mental/Behavioral health/Substance use disorder (outpatient)

Office vist: $30 / Other than office visit: $0

Home health care services (100 visits per calendar year)


Other services
Durable medical equipment


Hospice service


Self-injectables (other than insulin)

20% up to $250/30-day script

Prescription drug coverage4
(up to a 30-day supply obtained through a participating pharmacy)
Tier I (most generics and low-cost preferred brands)


Tier II (non-preferred generics and preferred brands)


Tier III (non-preferred brands only)


Tier IV (Specialty drugs)

20% up to $250/30-day script

Pediatric dental5,6 Diagnostic and preventive services


Pediatric vision5,7 Routine eye exam


Glasses (limitations apply)

1 pair per year

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.

3Covered 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.

4The 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.

5Pediatric dental and vision are included on all plans.

6The 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.

7The 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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