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Blue Cross Individual Select HMO (PE43)

Select Another Plan

Determine the rates for the medical plan you selected and other available plans by clicking on the Get a Personalized Quote link on the left.

Lifetime Maximum

Unlimited
Annual Out-of-Pocket Maximum
(includes deductible)

$3,000/single (2-member maximum)
Annual Deductible

No deductible
Office Visits

You pay $25
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.)

$25 office visit Co payment, No charge for office visit related services
Hospital Inpatient/Outpatient

Inpatient — $250 per day Co payment, four (4) day Co payment maximum per admission
Outpatient — you pay 20% of negotiated fee (for non-emergency services)
Emergency Services

Professional services — no charge when authorized by a medical group within 48 hours of emergency care
Outpatient — you pay $100 emergency room co payment plus 20% of the negotiated fee rate (waived if admitted into the hospital)

Inpatient - $250 per day Co payment, four (4) day Co payment maximum per admission.
Maternity

Professional Services: $25 office visits Inpatient Services: $250 per day Co payment, four (4) day Co payment maximum per admission
Preventive Care

You pay a $25 co payment for specific health maintenance services
Ambulance

You pay a $50 Co payment unless admitted to the hospital
Physical and Occupational Therapy; Chiropractic Services

You pay $25 per visit; limited to 60 consecutive days following illness or injury; no charge for inpatient services Chiropractic benefits with medical group referral
Drug Benefits
(retail or mail order: 30-day supply)
Participating Provider
You pay $10 for generic and $30 for Brand drugs, after a $250 deductible for Brand drugs

Non-Formulary:Participating Provider: Generic 50%; Brand 100% of negotiated Fee Rate for Brand Name Drugs until the Brand Name Prescription Drug Deductible is satisfied. After the Brand Name $250 Drug Deductible is satisfied, 50% of the Negotiated Fee Rate for Brand Name Drugs if no Generic Equivalent is available.

If you select a Brand Name Drug when a generic equivalent is available even if a physician writes a “dispense as written” or “do no substitute” prescription you pay the generic drug Co payment plus the cost between the Brand Name drug and the generic drug. None of the amount paid applies toward your Brand Name Drug Deductible.
Non-participating Provider
50% of drug Limited Fee Schedule within California less the Co payment/Coinsurance stated for participating pharmacies

Notes:
• When locating a provider, please choose a participating Select HMO provider from the Power Select HMO network
• These plans do not cover services by non-participating providers except for emergency services and prescription drug benefits.
• Generic drugs are based on the Blue Cross drug formulary.
• The Brand drug deductible does not apply to the out-of-pocket maximum.
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