Health Net California – PPO Simple Choice 15 – California

A comparison of the PPO Simple Choice 15 offered by HNCA is detailed out below for both Network and Non-Network coverage.

• Compare to other Health Net California plans.

• Compare to all carriers in California.

	Network	Non-Network
Network	See Provider	See Provider
Application	PPO Simple Choice 15 Application	PPO Simple Choice 15 Application
Brochure	PPO Simple Choice 15 Brochure	PPO Simple Choice 15 Brochure
Copay	$15	$15
Office Visit	see brochure	see brochure
Deductible	$1,500, 2 per family	$1,500, 2 per family
Coinsurance	N/A	50%
Coinsurance Limit	see brochure	see brochure
Out-of-Pocket Maximum	Each member must meet calendar year deductible only / 2 per family	$10,000 / 2 per family combined in- and out-of-network
Lifetime Maximum	$6,000,000	$6,000,000
Prescription Drugs	Outpatient Prescription Drugs - filled at participating pharmacy (up to 30-day supply) $5 Level I (generic) $250 brand deductible $35 Level II (brand) $50 Level III (non-formulary)	Not Covered
Emergency Room	Covered in full after deductible is met	Covered in full after deductible is met
Adult Preventative Care	$15 (Deductible Waived)	$15 (Deductible Waived)
Child Preventative Care	$15 (Deductible Waived)	$15 (Deductible Waived)
Lab / X-Ray	Covered in full after deductible is met	50%
Maternity	Not Covered	Not Covered
Physical Therapy	Covered in full after deductible is met	50%
Skilled Nursing	see brochure	see brochure
Home Health Care	see brochure	see brochure
Mental Health	see brochure	see brochure
Hospital Care	Covered in full after deductible is met	50%
Optional Benefits	see brochure	see brochure