Anthem Blue Cross – Blue Cross of California HMO Saver – CALIFORNIA

A comparison of the Blue Cross of California HMO Saver offered by BCCA is detailed out below for both Network and Non-Network coverage.

• Compare to other Anthem Blue Cross plans.

• Compare to all carriers in CALIFORNIA.

	Network	Non-Network
Network	See Provider	See Provider
Application	Blue Cross of California HMO Saver Application	Blue Cross of California HMO Saver Application
Brochure	Blue Cross of California HMO Saver Brochure	Blue Cross of California HMO Saver Brochure
Copay	$10	$10
Office Visit	Unlimited office visits, $10 copay	Unlimited office visits, $10 copay
Deductible	$1,500/member Inpatient hospital services, outpatient Ambulatory Surgical Centers only	$1,500/member Inpatient hospital services, outpatient Ambulatory Surgical Centers only
Coinsurance	80%	80%
Coinsurance Limit	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver
Out-of-Pocket Maximum	$3,000/single (2-member maximum)	$3,000/single (2-member maximum)
Lifetime Maximum	Unlimited	Unlimited
Prescription Drugs	Blue Cross Formulary Drugs (Amounts shown are for each 30-day retail or mail order supply) $10 copay generic; after $250 brand-name prescription drug deductible (2-member maximum), $30 copay brand-name (if a brand-name is selected when a generic equivalent is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug (doesn't apply to brand-name deductible). 30% of negotiated fee for self-administered injectables, except insulin Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent.	Blue Cross Formulary Drugs (Amounts shown are for each 30-day retail or mail order supply) $10 copay generic; after $250 brand-name prescription drug deductible (2-member maximum), $30 copay brand-name (if a brand-name is selected when a generic equivalent is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug (doesn't apply to brand-name deductible). 30% of negotiated fee for self-administered injectables, except insulin Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent.
Emergency Room	Inpatient and professional services no charge when authorized by a medical group within 48 hours of emergency care Outpatient you pay $100 emergency room copayment plus 20%	You pay 20% for professional services
Adult Preventative Care	You pay a $10 copayment for specific health maintenance services	Blue Cross of California HMO Saver
Child Preventative Care	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver
Lab / X-Ray	Unlimited office visits: you pay $10 copay per visit Inpatient hospital no charge	Unlimited office visits: you pay $10 copay per visit Inpatient hospital no charge
Maternity	Office visits, Inpatient and outpatient paid as above (inpatient and outpatient subject to deductible)	Office visits, Inpatient and outpatient paid as above (inpatient and outpatient subject to deductible)
Physical Therapy	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	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
Skilled Nursing	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver
Home Health Care	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver
Mental Health	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver
Hospital Care	Subject to $1,500 deductible. Inpatient: 20% of negotiated fee. Outpatient: 20% of negotiated fee (emergency and non-emergency services are subject to the deductible).	Subject to $1,500 deductible. Inpatient: 20% of negotiated fee. Outpatient: 20% of negotiated fee (emergency and non-emergency services are subject to the deductible).
Optional Benefits	Blue Cross of California HMO Saver	Blue Cross of California HMO Saver