HMO

The HMO plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: HMO

Deductible: None

In-Patient Hospital Co-Payment/Coinsurance: 20%

Prescription Drug Coverage (Out Patient): Yes

Maternity Coverage Included: 20%

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HMO Summary:

	In Network	Out of Network
Annual Deductible	None	Not Applicable
Annual Out-Of-Pocket Limit	$3,000/member (See brochure)	Not Applicable
Lifetime Maximum	Not Applicable	Not Applicable
Office Visits	$10 (Maternity OV included)	Not Applicable
Prescription Drugs	Generic: $10 Brand: $30 ($250 Brand Deductible; 2 member max)	Not Applicable
Laboratory and Radiology	No Charge after Deductible	Not Applicable
Annual Physical Exam	No Charge	Not Applicable
Annual OB-GYN Exam	No Charge	Not Applicable
Well Baby Care	No Charge	Not Applicable
Outpatient Surgery	20% of negotiated fee	Not Applicable
Emergency Room	20% of negotiated fee plus $100 (Waived if admitted)	20% of negotiated fee plus $100 (Waived if admitted)
Ambulance	$50 (Waived if admitted)	$50 (Waived if admitted)
Home Health Care	See Brochure	Not Applicable
Mental Health Services - Outpatient	See Brochure	See Brochure
Chiropractic Care	See Brochure	See Brochure
Acupuncture / Acupressure	Not Covered	Not Applicable
Inpatient Hospital	20% of negotiated fee;	Not Applicable
Maternity Care	20% of negotiated fee	Not Applicable
Mental Health - Inpatient	See Brochure	See Brochure
Chemical Dependency	See Brochure	Not Applicable

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.