Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

HMO (Health Maintenance Organization)

HMOs are the least expensive option but also have the most restricted access to care. For a set monthly fee, HMOs offer a range of health benefits, including preventive care. Plans cover only the cost of doctors in the HMO, so you will have to pay the bill when visiting a doctor outside of the HMO.

In an HMO, you will choose a primary care physician (PCP) from a given list of doctors, who will coordinate your care. This includes:

• Routine and preventive care
• Treatment for illness and injuries
• Referrals to a network specialist or facility when necessary

With some HMOs, there is no fee for doctor visits, but with others you may need to pay a coinsurance, like $5 or $10, for various services.

Providers:

BLUE SHIELD

Access+ HMO Plan

Features-

• For people who visit the doctor more frequently
• Option to visit a participating specialist without a referral - for a $30 copayment
• Preventive care services at no charge
• Prescription generic drugs only $10 per prescription at participating pharmacies
• Extensive network from which to choose a Primary Care Physician - office visits with your PCP for a $10 copayment

Rates-

Access + HMO Plan Benefits	Individual Coverage	Two-Party/Family Coverage
Deductibles	$1,500	$3,000
Physician Services (i.e. office visits)	$10/visit	$10/visit
Prescription Drug Coverage (at participating pharmacies) - Generic Drugs - Brand-name Formulary Drugs	$10/prescription $30/prescription	$10/prescription $30/prescription
Monthly Rates	$170	Two-Party - $330 Family - $ 512

BLUE CROSS PLAN COMPARISON

	HMO	HMO Saver
Annual Out-of-Pocket Maximum (includes deductible)	$3,000 per single	$3,000 per single
Annual Deductible	No deductible	$1,500 per member
Office Visits	$10	$10
Drug Benefits	$10 for generic and $30 for Brand drugs, plus a $250 deductible for Brand drugs	$10 for generic and $30 for Brand drugs, plus a $250 deductible for Brand drugs
Monthly Rates	Individual - $226 Two-Party - $444 Family - $797	Individual - $156 Two-Party - $279 Family - $559

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