Blue Cross of California Individual Select HMO Plan Information

Plan Type: HMO

Physician Choice: General practitioner chooses specialist(s)

Annual Out-of-Pocket Maximum (includes deductible): $3000/member, 2 member maximum

Annual Deductible: No deductible

Office Visits: $25 Copayment

Professional Services: $25 office visit Copayment. No charge for office visit related services.

Hospital Inpatient/Outpatient: Inpatient Services: $250 per day Copayment, four (4) day Copayment maximum per admission. Outpatient Services: 20% of Negotiated Fee Rate (NFR).

Emergency Services: Inpatient Services: $250 per day Copayment, four (4) day Copayment maximum per admission. Outpatient Services: $100 emergency room Copayment plus 20% of the Negotiated Fee Rate (NFR). Professional Services: No Charge.

Maternity: Inpatient Services: $250 per day Copayment, four (4) day Copayment maximum per admission. Professional Services: $25 office visit Copayment. No charge for office visit related services.

Preventive Care - General: $25 Copayment

Drug Benefits: Generic: $10 Copayment. Brand Name Drugs After $250 Brand Name Deductible: $30 Copayment. Self-Administered Injectable Drugs (except Insulin): 30% of the Negotiated Fee Rate (NFR). Non-Formulary: 50% of the Negotiated Fee Rate (NFR).

Financial/Tax Incentive: No

Specialty Pharmacy Drug Benefit: Certain drugs will be obtainable only through Precision Rx Specialty Solutions

Other Blue Cross of California health insurance plans:

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