Individual HMO Plan
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PDF versionNo medical deductible with full network access For the most complete HMO coverage, Individual HMO offers you:
- No medical deductible. Benefits are immediate with easy copays for doctor visits.
- Access to our entire HMO provider network with nearly 300,000 doctors and 400 hospitals across California.
- Maternity benefits. Important for growing families.
- Brand-name and generic prescription drug coverage with an affordable $10 copay on generic drugs.
- Emergency coverage that travels with you. If you travel out of state, you can rest assured that you’ll be covered in case of an emergency.
For extra security, we offer dental and life insurance plans that you can add to your medical coverage. If you have questions:
- Click here for our Individual HMO brochure
Benefits-at-a-glance for the Individual HMO plan
| Plan Benefits | Select HMO | HMO Saver | Individual HMO | ||
| In-Select Network1 | In-Network | In-Network | |||
| Annual Deductible | $0 | $1,500 per member Inpatient / Outpatient Hospital Services and Ambulatory Surgical Centers |
$0 | ||
| Annual Out-Of-Pocket Limit (in addition to deductible, if any) | Individual | $3,000 per member | $1,500 per member | $3,000 per member | |
| Family | Each family member has an individual out-of-pocket limit. Once 2 members each reach the limit, the maximum is satisfied for the entire family | Each family member has an individual out-of-pocket limit. Once 2 members each reach the limit, the maximum is satisfied for the entire family |
Each family member has an individual out-of-pocket limit Once 2 members each reach the limit, the maximum is satisfied for the entire family |
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| Lifetime Maximum (the plan will pay up to this amount) |
Unlimited | unlimited | unlimited | ||
| Covered Services The amounts shown are your share of costs after any deductible | In-Select Network1 | In-Network | In-Network | ||
| Doctors’ Office Visits | $25 copay | $10 copay per visit | $10 copay per visit | ||
| Professional Services (x-ray, lab, anesthesia, surgeon, etc.) |
No charge for office visit-related services |
No charge for office visit-related services |
No charge for office visit-related services |
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| Hospital Inpatient (overnight hospital stays) |
$250 copay per day up to the first four days, then 0% of negotiated fee per admission |
20% of negotiated fee (after deductible) |
20% of negotiated fee | ||
| Hospital Outpatient (if you don’t stay overnight) |
20% of negotiated fee for services; $250 per surgery |
20% of negotiated fee (after deductible) |
20% of negotiated fee | ||
| Emergency Room Services ($100 copay applies for each visit; waived if admitted as inpatient) |
20% of negotiated fee | 20% of negotiated fee (after deductible) |
20% of negotiated fee | ||
| Maternity | Office Visits: $25 copay Hospital Inpatient: $250 copay per day up to the first four days, then 0% of negotiated fee per admission Outpatient Services: 20% of negotiated fee |
Office visits: $10 copay Inpatient/Outpatient: 20% of negotiated fee (after deductible) |
Office visits: $10 copay Inpatient: No charge Outpatient: 20% of negotiated fee |
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| Preventive Care | $25 copay for specific health maintenance services |
$10 copay for specific health maintenance services |
$10 copay for specific health maintenance services |
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| Ambulance | $50 copay (waived if admitted to hospital) |
$50 copay (waived if admitted to hospital) |
$50 copay (waived if admitted to hospital) |
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| Chiropractic Services (up to 60 consecutive days following an illness or injury; provided with medical group referral only) |
Inpatient | $0 | $0 | $0 | |
| Outpatient | $25 copay per visit | $10 copay per visit | $10 copay per visit | ||
| Prescription Drug Benefits | Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible2 (2 member maximum) |
Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible2 (2 member maximum) |
Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible2 (2 member maximum) |
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1. The Select HMO uses a smaller network of doctors and hospitals than the HMO Saver and Individual HMO.
2. The brand-name drug deductible does not apply to the out-of-pocket limit.
Note: In order to receive HMO benefits, you must choose a provider within a 30-mile radius of your home or work. The HMO plans do not cover services by non-participating providers except for emergency services and prescription drugs.
