Blue Cross HMO
| This HMO Plan is only available in Rating areas 4,5,& 6 | |
| Annual Deductible | None |
| Coinsurance Paid by Blue Cross & Your Share | 80% / 20% |
| Your Maximum Out of Pocket Costs | $3,000/ Two per Family |
| Your Choice of Physicians | You must choose a Physician from the |
| Directory as your Personal Physician | |
| Lifetime Benefit | Unlimited |
| Pre-existing Condition/s Waiting Period | None |
| Office Visits-your portion | $10 CoPay |
| Hospitalization - (Inpatient) | Plan Pays 100% |
| Maternity | Additional $1,000 Copay |
| Outpatient Surgery- your portion | 20% |
| Laboratory & X-Ray | No Charge |
| Ambulance | $50 CoPay (Waived if admitted) |
| Emergency Services - Within Service Area* | Inpatient & Professional services - no charge when authorized by medical group within 48hrs |
| Outpatient services - you pay $50 CoPay plus 20% | |
| Emergency Services - Outside Service Area* | You pay $100 CoPay + 20% |
| Mental Health Services (inpatient & outpatient) are covered as any other illness for SEVERE conditions. | |
| Non-severe Mental Health visits are limited to: | 20 visits per year |
| Acupuncture | Not Covered |
| Chiropractic Care | Requires medical group referral & must be 60 days following illness or injury; $10 CoPay |
| PREVENTIVE CARE | |
| Well Baby Care / Well Woman Care | $10 CoPay |
| OUT PATIENT Rx COPAYS | $10 Generic / $30 Brand Name |
| (Retail or Mail Order) | (Brand Name CoPay applies |
| after a $250 Deductible) | |
| (2 Deductible maximum per family) | |
| * For emergency services, the service area is a 20 mile radius from your participating medical group. | |
| For Alternative Medicine, Blue Cross policies include 'Healthy Extensions', which offers discounts on products and services. | |
| NOTE: This is a Summary of Benefits and assumes Member uses PARTICIPATING PROVIDERS. Benefits are not covered if NON-PARTICIPATING PROVIDERS are used, except for Emergency Services. | |