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Blue Cross of California Health Insurance Plan

Individual HMO
In­Network Benefits
Annual Deductible(s)
Take advantage of participating provider discounts before and after meeting the deductible.

No deductible
Annual Out-of-Pocket Maximum(includes deductible)
Participating and non-participating provider covered services apply.

$3,000 per member Once 2 members each reach the maximum, the maximum is satisfied for the entire family.
Doctors' Office Visits

$10 copay
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.).

No charge for office­related services
Hospital Inpatient/Outpatient.

20% of negotiated fee
Emergency Room Services
(Additional $100 copay applies; waived if admitted).

$100 emergency room copay, plus 20% of negotiated fee; copay waived if admitted to hospital
Maternity

Office Visits: $10 copay Inpatient/Outpatient: 20% of negotiated fee
Preventive Care

$10 copay for specific health maintenance services
Prescription Drugs
(Amounts shown are copays for each 30-day retail or mail order supply).

Blue Cross Formulary Drugs: $10 generic; $30 brand­name 1 copay after $250 brand­name deductible (2­member maximum); 30% of negotiated fee for self­ administered injectables, except insulin
Other Information.

1 If you select a brand­name drug when a generic equivalent drug is available, even if the physician writes a ``dispense as written'' or ``do not substitute'' prescription, you will be responsible for the generic copay plus the difference in cost between the brand­name drug and the generic equivalent drug. None of the amount paid applies to the member's brand­name drug deductible.