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Published byBaldwin Gordon Modified over 9 years ago
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SmartSense PPO Plans New Plan Design Launched December 2007
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2 SmartSense From Anthem Blue Cross Life and Health Insurance Company
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3 SmartSense Highlights Reliable protection with some of our lowest monthly rates Choice of annual deductible/monthly rate combination In-network office visits available before deductible Choice of prescription drug benefits (Generic Only or Comprehensive) $7 million lifetime maximum benefit
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4 SmartSense Benefits In-NetworkOut-of-Network Deductible Individual/Family$5,000/$10,000 Separate in-network and out-of-network deductibles Embedded (family) deductibles Once a member meets their single deductible, their deductible is satisfied. After any one family member meets the single deductible, then two or more family members can meet the family deductible. 4 th Quarter carry-over deductible feature 4 OPTIONS $500/$1,000 $1,500/$3,000 $2,500/$5,000 $5,000/$10,000
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5 SmartSense Benefits In-NetworkOut-of-Network Coinsurance30%50% Annual OOP Maximum Individual/Family $2,500/$5,000$10,000/$20,000 Lifetime Maximum$7 million Separate in-network and out-of-network OOP Maximum OOP maximum amount shown is in addition to deductible
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6 In-NetworkOut-of-Network Physician Office Visits $30 copay for first 3 visits then in-network deductible and 30% coinsurance 50% coinsurance after out-of-network deductible plus all excess charges In/Outpatient Hospital Care 30% coinsurance after in-network deductible IP: All charges except $650/day OP: All charges except $380/day Emergency Care additional $100 co-pay per ER visit (waived if admitted) 30% coinsurance after in-network deductible 50% coinsurance after out-of-network deductible plus all excess charges MaternityNot Covered SmartSense Benefits
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7 In-NetworkOut-of-Network Routine Care Routine Mammogram Routine Pap Smear & PSA Routine Colorectal Cancer Screenings Preventive Care & Immunizations for Children (Birth to 6 years) 30% coinsurance after in-network deductible 50% coinsurance after out-of-network Deductible plus all excess charges 3 office visits before deductible HealthyCheck not available
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8 SmartSense Benefits In-NetworkOut-of-Network Ambulance Services 30% coinsurance after in-network deductible 50% coinsurance* after out-of-network deductible Acupuncture/ Acupressure Not Covered Chiropractic Care 30% coinsurance after in-network deductible, $500 limit 50% coinsurance* after out-of-network deductible, $500 limit Outpatient Speech/Physical/ Occupational Therapy 30% coinsurance after in-network deductible, $2,500 limit 50% coinsurance* after out-of-network deductible, $2,500 limit *Plus all excess charges
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9 SmartSense Benefits Choose your Pharmacy Benefit! Generic Rx Only Comprehensive Rx
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10 SmartSense Benefits Pharmacy Benefits In-NetworkOut-of-Network Generic Drugs on Generic Rx Formulary Only $15 co-payment or 40% coinsurance (member pays whichever is greater) Brand Name Not Covered Discount Available Not Covered Generic Rx Only
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11 In-NetworkOut-of-Network Generic$15 co-payment or 40% coinsurance (member pays whichever is greater) Brand Name$500 annual brand-name/ specialty deductible, then $15 co-payment or 40% coinsurance (whichever is greater) $500 annual brand-name deductible, then $15 co-payment or 40% coinsurance (whichever is greater) SmartSense Benefits Pharmacy Benefits Comprehensive Rx 2-member maximum on deductible
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12 In-NetworkOut-of-Network Generic$15 co-payment or 40% coinsurance (member pays whichever is greater) Brand Name$500 annual brand-name/ specialty deductible, then $15 co-payment or 40% coinsurance (whichever is greater) 40% of negotiated fee for Specialty Drugs and self-administered injectables, except insulin $4,500 annual OOP Maximum $500 annual brand-name deductible, then $15 co-payment or 40% coinsurance (whichever is greater) 40% of negotiated fee for self-administered injectables, except insulin No Specialty Drug Coverage SmartSense Benefits Pharmacy Benefits Comprehensive Rx Specialty Drugs include injected, infused, oral and inhaled medications that generally need to be closely monitored by the member’s doctor. The most a member would have to pay. This is in addition to the deductible.
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13 Selling SmartSense One of our lowest priced plans with solid protection that covers the essentials In-network office visits available before deductible $500 - $5,000 range of deductibles Embedded deductible Choice of annual deductible/monthly rates to fit any budget Choice of prescription drug benefits (comprehensive or generic only) Lifetime maximum benefits of $7,000,000 4 th Quarter deductible carry-over
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14 Rating Differences Gender Rating Single Age Bands Rates by Number of Members
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15 Gender Rating Allows us to more appropriately and accurately rate by gender Single Age Bands Smaller age-related increases than for plans with multi-year age bands Rates by Number of Members For one-member contracts, there is one set of rates For two or more SmartSense members on a contract, there is a discounted rate Rating Differences
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16 Questions? Thank you! The SmartSense plans are offered by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.
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