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Blue Cross of California HMO Saver (7896) 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 $1,500/member Inpatient hospital services, outpatient Ambulatory Surgical Centers only Office Visits You pay $10 Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.) Unlimited office visits: you pay $10 per visit Inpatient hospital — no charge Hospital Inpatient/Outpatient Inpatient — no charge after $1,500 deductible for non-emergency services Outpatient — you pay 20% of negotiated fee after $1,500 deductible for non-emergency services (for non-emergency services) Emergency Services Inpatient and 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% Maternity Professional Office Visit you pay $10 co payment Hospital – no charge after $1,500 deductible Outpatient Hospital – 20% after $1,500 deductible. Preventive Care You pay a $10 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 $10 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, plus 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 Non-participating Provider You pay a $250 Brand deductible; then 50% of drug Limited Fee Schedule within California Notes: • When locating a provider, please note that HMO plans are also referred to as California Care • These plans do not cover services by non-participating providers except for emergency services and prescription drug benefits. • The HMO Saver plan deductible pertains to non-emergency inpatient and outpatient facility charges and Ambulatory Surgical Centers (does not include professional services). • 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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