HMO medical coverage California for individuals, family and groups

Authorized Agent

Blue Cross of California*
* is an Independent Licensee of the Blue Cross Association

GERRY CACCAMO
A-ADVANTAGE INSURANCE SERVICES
Calif. Lic #OB22296

1200 E. ROUTE 66 #108 GLENDORA, CALIFORNIA 91740
800-246-3330 or 626-857-9230

INSTANT HEALTH QUOTE

APPLICATION FORMS DOWNLOAD

DENTAL INSURANCE RATES

HMO OVERVIEW (In order to receive HMO benefits, you must choose a provider within a 30 miles radius of your home or work.)		VIEW RATES
Benefit	HMO Saver (7896) In-Network	Individual HMO (7898) In-network
Benefit	These amounts show your share of costs
Annual Deductible	$1,500/member; Inpatient/Outpatient Hospital Services and Ambulatory Surgical Centers	$0
Lifetime Maximum	Unlimited
Annual Out-of-Pocket Maximum	$3,000 per member Once two members each reach the maximum, the maximum is satisfied for the entie family (includes deductibel)	$3,000 per member Once two members each reach the maximum, the maximum is satisfied for the entie family
Doctor's Office Visits	$10 copay per visit
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)	No charge for office visit-related services
Hospital Inpatient (Overnight Hospital Stays)	20% of negotiated fee (after deductible)	20% of negotiated fee
Hospital Outpatient (If You Don't Stay Overnight)	20% of negotiated fee (emergency and non-emergency services are subject to the deductible)	20% of negotiated fee
Emergency Room Services³	20% of negotiated fee (after deductible)	20% of negotiated fee
Maternity	Office visits: $10 copay Inpatient/Outpatient: After deductible, 20% of negotiated fee	Office visits: $10 copay Inpatient/Outpatient: 20% of negotiated fee
Preventive Care	$10 copay for specific health maintenance services
Ambulance	$50 copay waived if admitted to the hospital
Physical and Occupational Therapy; Chiropractic Services (Up to 60 consecutive days following an illness or injury)	Outpatient: $10 copay per visit Inpatient: 20% of negotiated fee Chiropractic services provided with medical group referral only
Acupuncture/Acupressure	Not Covered
Prescription Drugs Blue Cross Formulary Drugs^1: (Amounts shown are copays for each 30-day retail or mail order supply)	$10 copay generic; $30 copay brand-name² after $250 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self-administered injectables, except insulin

¹ Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to the brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent.

² If a member selects a brand-name drug when a generic equivalent drug 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. The amount paid does not apply to the memeber's brand-name deductible.

³ Additional $100 copay applies for each emergency room vist. Waived if admitted as inpatient.