Anthem Blue Cross of California
Select HMO Health Insurance Plan
A plan summary of the Anthem Blue Cross of California Select HMO Plan is detailed out below for both Network and Out of Network coverage.
| Network |
Out of Network |
| Copay |
$25 |
Not Applicable |
| Office Visits |
$25 (Maternity OV included) |
Not Applicable |
| Annual Deductible |
None |
Not Applicable |
| Annual Out-Of-Pocket Limit |
$3,000 / member (See brochure) |
Not Applicable |
| Lifetime Maximum |
Not Applicable |
Not Applicable |
| Prescription Drugs |
Generic: $10
Brand: $30
($250 Brand Deductible; 2 member max) |
Not Applicable |
| Laboratory & X-Ray |
No Charge after Deductible |
Not Applicable |
| Annual Physical Exam |
No Charge |
Not Applicable |
| Annual OB-GYN Exam |
No Charge |
Not Applicable |
Well Baby Care |
No Charge |
Not Applicable |
| Outpatient Surgery |
20% of negotiated fee; $250/surgery |
Not Applicable |
| Emergency Room |
20% of negotiated fee plus $100 (Waived if admitted) |
20% of negotiated fee plus $100 (Waived if admitted) |
| Inpatient Hospital |
$250 / day (4 day maximum / admission) |
Not Applicable |
| Ambulance |
$50 (Waived if admitted) |
$50 (Waived if admitted) |
| Home Health Care |
See Brochure |
Not Applicable |
| Mental Health - Outpatient |
See Brochure |
Not Applicable |
| Chiropractic Care |
See Brochure |
Not Applicable |
Acupuncture |
Not Covered |
Not Applicable |
| Mental Health - Inpatient |
See Brochure |
Not Applicable |
| Chemical Dependency |
See Brochure |
Not Applicable |
| Maternity Care |
$250 / day (4 day maximum / admission) |
Not Applicable |
To learn more about your
individual and family
California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
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