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SmartSense 500 Upgrade Rx 1 MemberAnthem Logo

Blue Cross SmartSense 500 Upgrade Rx Member Plan Information

The SmartSense 500 Upgrade Rx 1 Member plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: PPO
Deductible: $10,000
In-Patient Hospital Co-Payment/Coinsurance: $0
Prescription Drug Coverage (Out Patient) Yes
Maternity Coverage Included: No


SmartSense 500 Upgrade Rx 1 Member Summary:

In Network Out of Network
Annual Deductible Individual: $500 Family: $1,000 Individual: $5,000 Family: $10,000
Annual Out-Of-Pocket Limit Individual: $2,500 Family: $5,000 (Deductible not Included) Individual: $10,000 Family: $20,000 (Deductible not Included)
Lifetime Maximum $7,000,000 $7,000,000
Office Visits $30 for first three visits/member/year, 4+ visits 30% 50%
Prescription Drugs Generic: $15 Brand Formulary: $40 Brand Non-Formulary: $60 ($500 Brand Annual Deductible) Not Covered
Laboratory and Radiology 30% 50%
Annual Physical Exam 30% or $25/$75 Co-Pay at HealthyCheck Centers for Basic/Premium Screening 50%
Annual OB-GYN Exam 30% 50%
Well Baby Care 30% 50%
Outpatient Surgery 30% All Charges Except $380/day after Deductible
Emergency Room 30% plus $100 (Waived if admitted) No Charge after Deductible
Ambulance 30% 50%
Home Health Care 30% 50%
Mental Health Services - Outpatient See Brochure See Brochure
Chiropractic Care 30% 50%
Acupuncture / Acupressure Not Covered Not Covered
Inpatient Hospital 30% All charges except $650/day
Maternity Care Not Covered Not Covered
Mental Health - Inpatient See Brochure See Brochure
Chemical Dependency See Brochure See Brochure


IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.


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California Health Plans, a division of Dave Terpening Insurance Agency, Inc.  |   22850 Crenshaw Blvd. #206  |   Torrance, CA 90505
Copyright © 2017 Dave Terpening Insurance Agency, Inc. |  CA Lic# 0G47857
Blue Cross of California is an independent licensee of the Blue Cross Association. The Blue Cross name and symbol are registered service marks of the Blue Cross Association.

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