Anthem Blue Cross - California
HMO Saver & Individual HMO Plan
It's All About Simplicity
Blue Cross of California's HMO could be the right choice if you want to simplify decision-making, get valuable benefits and pay predictable out-of-pocket costs. We offer you three Blue Cross of California HMO Choices:
The Select HMO Plan utilizes its own network in 22 California counties, so more people can take advantage of comprehensive coverage at lower monthly premiums.
The HMO Saver Plan offers comprehensive coverage, and its annual $1,500 deductible design helps monthly premiums lower. With this plan you'll pay just a $10 copay for doctors' office visits and preventive care.
The Individual HMO Planprovides immediate, no-deductible, comprehensive benefits. If you enroll in one of the Blue Cross HMO Plans, you'll choose a primary care physician to coordinate your health care services. That doctor will also authorize referrals to any specialists you may need. Consider a Blue Cross of California HMO plan if you want to simplify decision making and pay predictible out-of-pocket costs.
To enroll, you must be:
Age 64 3/4 or younger
A permanent legal resident of California
A U.S. resident for at least the lst 3 months
The applicant's spouse or domestic partner, age 64 3/4 or younger
The applicant's children (under 19 years of age), or the children (under 19 years of age) of the applicant's enrolling spouse or qualified partner or qualified domestic partner;
The applicant's unmarried dependent children between the ages of 19 through 22 ("dependent" as defined by the Internal Revenue Service)
$1,500 per member: Inpatient/Outpatient Hospital Services and Ambulatory Surgical Centers
$0
Lifetime Maximum
Unlimited
Annual Out-of-Pocket Maximum
$3,000 per member: Once two members each reach the maximum, the maximum is satisfied for the entire family (includes deductible)
$3,000 per member: Once two members each reach the maximum, the maximum is satisfied for the entire family
Doctors' Office Visits
$10 copay per visit
Professional Services (X-ray, lab, anesthesia, surgeon, etc.)
No Charge for office visit-related services
No Charge for office visit-related services
Hospital Inpatient (Overnight Hospital Stays)
20% of negotiated fee (after deductible)
20% of negotiated fee
Hospital Outpatient (If You Don't Stay Overnight)
20% of negotiated fee (emergency and non-emergency services are subject to the deductible)
20% of negotiated fee
Emergency Room Services
20% of negotiated fee (after deductible)
20% of negotiated fee
Maternity
Office visits:$10 copay Inpatient/Outpatient: After deductible, 20% of negotiated fee
Office visits:$10 copay Inpatient/Outpatient: 20% of negotiated fee
Preventive Care
$10 Copay for specific health maintenance services
$10 Copay for specific health maintenance services
Ambulance
$50 Copay waived if admitted to hospital
$50 Copay waived if admitted to hospital
Physical & Occupational Therapy; Chiropractic Services (up to 60 consecutive days following an illness or injury)
Outpatient: $10 Copay per visit
Inpatient: 20% of negotiated fee
Chiropractic services provided with medical group referral only
Accupunture/Accupressure
Not Covered
Prescription Drugs (Blue Cross Formulary)
Amounts shown are for each 30-day retail or in-network mail order supply
$10 copay generic; $30 copay brand-name after $250 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self administered injectables, except insulin
50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benfits; subject to the annual $500 brand-name prescription drug deductible.
