Blue Cross of California HMO Saver California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
HMO Saver
Plan Type
HMO
Primary Care Physician Required
Yes 
Specialist Referrals Required
Yes 
HSA Eligible
No 
Out-of-Network Coverage
No 
In-Network Coverage
Coinsurance
None 
Office Visit
 
Primary Doctor
$10 Copay, deductible waived 
Specialist
$10 Copay, deductible waived 
Periodic Health Exam
$10 Copay, deductible waived 
Periodic OB-GYN Exam
$10 Copay, deductible waived 
Well Baby Care
$10 Copay, deductible waived 
Chiropractic
$10 Copay, deductible waived, 60 consecutive days following an illness or injury 
Mental Health
Plan pays $25 per visit, up to 20 visits per calendar year 
Prescription Drugs
 
Generic
$10 Copay 
Brand
$30 Copay 
Non-Formulary
50% Coinsurance 
Separate Rx Deductible
$250 Individual
$500 Family
applies to
Brand 
Mail Order
Available
Outpatient Lab/X-Ray
No Charge for office visit-related services 
Emergency Room
$100 Copay (waived if admitted)
Plus 20% Coinsurance after deductible 
Outpatient Surgery
20% Coinsurance after deductible 
Hospitalization
20% Coinsurance after deductible 
Maternity
 
Pre & Postnatal Office Visit
$10 Copay, deductible waived 
Labor & Delivery Hospital Stay
20% Coinsurance after deductible 
Additional Information
Will insurance company obtain and pay for medical records?
Yes
eSign
(electronic signature)
Yes
A.M. Best Rating
A
as of 11/06/2006
More Insurance Plan Details
More Details
Exclusions and Limitations
Exclusions and Limitations
Actions
Company
Blue Cross of California
Plan Name
HMO Saver
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