California Health Insurance: Health Net Gold 80 PPO

Health Net Gold 80 PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $0 $5,000
Family Deductible  $0 $10,000
Out of Pocket Limit-Individual  $6,750 $25,000
Out of Pocket Limit-Family  $13,500 $50,000
Co-Insurance  20% 50% 
Lifetime Maximum  Unlimited Unlimited
Office Visits 
Primary Care  $30 50% after deductible
Specialist  $55 50% after deductible
Adult Preventive Care  No Charge Not Covered 
Child Preventive Care  No Charge Not Covered 
Maternity Prenatal/Postnatal Care  No Charge 50% after deductible
Rehabilitation Services  $30 Not Covered
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 20% 50% after deductible 
Maternity Delivery/Inpatient  20% 50% after deductible 
Outpatient Services 
Outpatient Facility  20%   50% after deductible
Mental Health Outpatient  No charge 50% after deductible 
Lab/X-Ray  $35/$55 50% after deductible
Emergency Care 
Emergency Room  $325 (waived if admitted) Paid as in-network
Urgent Care  $30   50% after deductible
Ambulance  $250  Paid as in-network
Prescription Drugs 
Rx Deductible  N/A N/A 
Rx Generic  $15 Not covered 
Rx Preferred  $55 Not covered 
Rx Non-Preferred  $75 Not covered 
Recovery/ Special Needs 

Home Health Care

20%; 100 visits per year

Not covered 

Durable Medical Equipment  20% 50% after deductible 
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Health Net Gold 80 PPO plan or any other plans from Health Net of California please call The Lynn Company at (800)-326-5966 for more information on California Health Insurance Plans
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