Blue Shield of California Access HMO Plans

Blue Shield of California offers 2 HMO plans on the individual and family health insurance market. Both of these plans limit your share of cost when receiving medical treatments that are covered under your plan. You select a primary care physician through the Blue Shield list of participating providers who will be in charge of monitoring your health status and referring you to a specialist when needed. Blue Shield even offers a guarantee on your satisfaction when using any of the primary care physicians within their network, which is one of the largest HMO networks in the state of California. There are no claim forms to file with the Access HMO plans and you have "direct access" that allows you to self-refer to specialists within the medical group of your primary care physician. There is no lifetime maximum benefit caps on the Blue Shield of California Access HMO plans.

Blue Shield of California Access+ HMO

This is the more comprehensive of the two HMO plans offered through Blue Shield of California. There is a $2,000 annual deductible that applies to inpatient and outpatient hospital and surgical procedures, but most other services are provided at a set copayment amount. Physician visits and lab and radiology are both covered for a $20 copayment, as are routine physical exams. For both outpatient surgery and hospital admittance, there is a $250 copayment in addition to your plan deductible. This copayment is required per visit, even after your deductible has been met. If your outpatient surgery is performed in an ambulatory surgery center, your copayment is only $20, after the deductible. The calendar year copayment maximum on the Access+ HMO plan is $3,000, which includes the plan deductible. Once you meet this maximum, you are exempt from making copayments on applicable services for the remainder of the calendar year. Emergency room visits require a copayment of $75, but that is waived if your emergency is serious enough to warrant admittance into the hospital. Prescription drugs are covered at $20 generic $70 brand, with a $200 annual deductible for brand only. Mental health benefits are provided at $20 per visit, limit 20 visits per year, for non-severe mental health conditions. Maternity benefits are provided at the same rate as inpatient hospitalization, $250 per admittance after you have met the plan deductible. The Access+ HMO plan includes supplemental dental benefits provided through the Access+ Dentist plan.

Blue Shield of California Access+ Value HMO

The Access+ Value has the lowest monthly premium of the two available HMO plans, but the deductible and required copayments for most covered services is higher. The calendar year copayment maximum, which includes the plan deductible of $2,000, is set at $4,000. This is $1,000 higher than the maximum on the Access+ HMO plan offered at the higher monthly premium. Office visits, lab and radiology, routine physical exams outpatient x-rays, inpatient physician visits and prenatal office visits are all covered for a $35 copayment, without having the meet the plan deductible. Both inpatient hospitalization and outpatient surgery require a 40% coinsurance until the calendar year copayment maximum has been met, and are both subject to the plan deductible. Prescription drug benefits are provided at $10 generic and $35 brand, after a separate deductible of $400 that applies only to brand name drugs. Only outpatient formulary drugs are covered if they are medically necessary, unless preauthorization is received. Emergency room visits are covered with a $150 copayment.

The information provided on this page is subject to change and may not be current. Check with the insurance company or your insurance agent for verification of details. The information provided is for comparison purposes only and is not legally binding. Always review the plan brochure or your policy details for complete and accurate details about this policy.