Blue Cross of California Individual Select HMO California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
Individual Select HMO
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
$25 Copay 
Specialist
$25 Copay 
Periodic Health Exam
$25 Copay 
Periodic OB-GYN Exam
$25 Copay 
Well Baby Care
$25 Copay 
Chiropractic
$25 Copay, 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 
Outpatient Surgery
$250 Copay per surgery plus 20% Coinsurance for services 
Hospitalization
$250 Copay per day for first 4 days, then no charge 
Maternity
 
Pre & Postnatal Office Visit
$25 Copay 
Labor & Delivery Hospital Stay
$250 Copay per day for first 4 days, then no charge 
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
Individual Select HMO
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