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A network that offers peace of mind
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Freedom to visit any provider in our diverse network*
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Access to second opinions from other medical groups in the network
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Have confidence knowing
that we partner with
high-quality providers
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Receive care from anywhere
with fully covered virtual
doctor visits**
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Anthem Blue Cross Select HMO basics
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Free preventive care
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Predictable out-of -pocket costs
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No annual deductible
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Access to the Mail Order
Pharmacy program
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Residents of the following counties are eligible for coverage:
Imperial, Kern, Los Angeles, Orange, Riverside, San Bernadino,
San Diego or Ventura
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What you pay for common services
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Benefit |
Anthem Blue Cross Select HMO |
Preventive care services |
No copay |
Non-preventive primary care providers
| $30 per office visit |
Specialists |
$40 per office visit |
Virtual doctor visits through the
Sydney Health App**
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No copay |
Urgent care centers |
$30 per visit |
Retail health clinic |
$30 per office visit |
Maternity |
$30 per office visit |
Infertility services |
Check Plan brochure for types of coverage
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Inpatient hospital |
$250 per day for a maximum of 4 days |
Outpatient hospital |
$250 per visit for surgical admissions or $40 per visit for other services |
Surgery Professional Services |
No copay unless performed during an office visit, then $30 per office visit to your
primary care physician (PCP) or $40 per office visit to a specialist
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Emergency care |
$150 per emergency room visit |
Lab, X-ray, and other
diagnostic tests
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No copay |
Advanced imaging procedures |
$125 per test |
Chiropractic care |
$15 per office visit 20 visits per calendar year
When you see a chiropractor in the American Specialty
Health Plans of California, Inc. (ASH Plans) network
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Mental health substance use care
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$30 per office visit |
Catastrophic protection Your out-of-pocket maximum |
Self Only: $3,000
Self + One: $6,000
Self & Family: $6,000
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Prescription drug coverage
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Anthem Blue Cross Select HMO |
Level 1 Retail Pharmacies (up to a 30-day supply at a Plan pharmacy) |
Tier 1 |
$10 copay |
Tier 2 |
$50 copay |
Tier 3 |
$80 copay |
Tier 4 |
25% of our allowance ($250 maximum per prescription)
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Level 2 Retail Pharmacies (up to a 30-day supply at a Plan pharmacy) |
Tier 1 |
$20 copay |
Tier 2 |
$60 copay |
Tier 3 |
$90 copay |
Tier 4 |
25% of our allowance ($250 maximum per prescription)
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Home Delivery Pharmacy |
Tier 1 |
$20 copay |
Tier 2 |
$100 copay |
Tier 3 |
$160 copay |
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Anthem Blue Cross Select HMO Premium
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Enrollment Code |
Biweekly |
Monthly |
Self |
B31 |
$99.93 |
$216.51 |
Self + One |
B33 |
$201.61 |
$436.82 |
Self & Family |
B32 |
$215.17 |
$466.20 |
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*You must stay in the network to receive care.
**Virtual doctor visits may also be accessed through LiveHealthOnline.com without a copay. Virtual care from your own doctor or another healthcare provider in the network may have a separate copay.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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