California Plan Benefits
Anthem Blue Cross Select HMO
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With Anthem Blue Cross Select HMO, you get more of what you want – more choices, more convenience and more control. That’s a lot of more. And with Anthem, you get a dedicated, dependable partner to join you on your journey.
Learn more about the Anthem Blue Cross Select HMO
Let's break down some more details of the Anthem Blue Cross Select HMO.
- You have to stay in network
- You'll have predictable out-of-pocket costs
- There's no annual deductible
Pharmacy Benefits
Prescription Drug Copays for 2022
Level 1 |
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|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $10 copay | $120.00 | $25 copay | $100.00 |
| Tier 2 | $50 copay | $600.00 | $110 copay | $440.00 |
| Tier 3 | $80 copay | $960.00 | $170 copay | $680.00 |
| Tier 4 | 25% of our allowance ($200 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
| Diabetic supplies | $10 copay | $120.00 | $10 copay | $40.00 |
| Compound drugs | $80 copay | $960.00 | 90-day supply is not available | 90-day supply is not available |
Level 2 |
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|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $20 copay | $240.00 | N/A | N/A |
| Tier 2 | $60 copay | $720.00 | N/A | N/A |
| Tier 3 | $90 copay | $1,080.00 | N/A | N/A |
| Tier 4 | 25% of our allowance ($200 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
| Diabetic supplies | $10 copay | $120.00 | N/A | N/A |
| Compound drugs | $80 copay | $960.00 | 90-day supply is not available | 90-day supply is not available |
*Please note that pricing information is based on filling prescriptions at a Level 1 pharmacy. Add $10 to your copay if you’re having your prescriptions filled at a Level 2 pharmacy.
