Anthem Blue Cross and Blue Shield - SmartSense
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SmartSense is the newest plan available for individuals and families from Anthem Blue Cross Blue Shield of Colorado. If offers reliable, standard protection with low monthly rates. SmartSense gives members a choice of prescription drug benefits and immediate benefits for your first 3 doctor visits all at a low co-payment that works for you. Members also have access to the Anthem PPO network that includes over 6,500 doctors and 80 hospitals in Colorado.
Specific financial benefits apply to both families and individuals with the SmartSense plan. Members can choose the deductible rate that accommodates their personal budget anywhere from $500 to $7,500 for individuals and up to $15,000 for families. Each family member has an individual deductible. A family deductible can be satisfied by 2 or more members.
Other SmartSense features include:
- A choice of deductibles, which gives you more control over your premium costs.
- Access to one of the largest PPO networks in Colorado with more than 6,500 doctors and 80 hospitals
- No referrals needed to see in-network specialists
- Preventive care benefits for well-child physician office visits, immunizations for children, and health screenings such as mammograms, pap tests and prostate cancer screenings.
- First doctor visits are covered at 100% after a $30 copay
- Out-of-state coverage through the BlueCard program when you're traveling
SmartSense - Outline of Coverage
| Plan Feature | In-Network You Pay | Out-of-Network You Pay3 |
| Deductible Options Each family member has an individual deductible. The family deductible can be satisfied by 2 or more members. |
$500 individual / $1,000 family $1,500 individual / $3,000 family $2,500 individual / $5,000 family $5,000 individual / $10,000 family $7,500 individual / $15,000 family |
$5,000 individual / $10,000 family $5,000 individual/ $10,000 family $5,000 individual/ $10,000 family $5,000 individual/ $10,000 family $7,500 individual/ $15,000 family |
| Out-of-Pocket Expense Limit Includes deductible. Each family member has an individual out-of-pocket maximum. The family out-of-pocket maximum can be satisfied by 2 or more members. |
$3,000 individual / $6,000 family1 $4,000 individual / $8,000 family1 $5,000 individual / $10,000 family1 $7,500 individual / $15,000 family1 $10,000 individual / $20,000 family1 |
$15,000 individual / $30,000 family1 $15,000 individual / $30,000 family1 $15,000 individual / $30,000 family1 $15,000 individual / $30,000 family1 $17,500 individual / $35,000 family1 |
| Lifetime Maximum Benefit | $7,000,000 per person | |
| Physician Office Visits | $30 co-pay for first 3 office visits per year. After 3 visits and deductible is met, then 30% | 50% |
| Professional Services X-ray, lab, anesthesia, surgeon, etc. |
30%2 | 50%2 |
| Urgent Care | 30%2 | 50%2 |
| Hospital Inpatient (Overnight hospital stays) |
30%2 | 50%2 |
| Hospital Outpatient (Non-overnight hospital stays) |
30%2 | 50%2 |
| Emergency Room | 30%2 | 50%2 |
| Maternity | Not Covered | |
| Preventive Care Includes appropriate screenings for breast, cervical, ovarian, and prostate cancer |
$30 copay per office visit when included in first 3 visits in calendar year. Mammogram and PSA test covered at no cost For colorectal screenings, 30% (deductible waived). |
50%2 |
| Well Child Care | 30% for childhood immunizations (under age 13) (deductible waived). 30% after deductible for other preventive services | 50%2 |
| Ambulance Ground and air. $3,000 maximum for ground services per calendar year, in and out-of-network combined. |
30%2 | 50%2 |
| Biologically-Based Mental Health Care Includes schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. |
Coverage is no less extensive than the coverage provided for any other physical illness. | |
| Other Mental Health Care | ||
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30%2 | 50%2 |
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30%2 | 50%2 |
| Alcohol & Substance Abuse | ||
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30%2 | 50%2 |
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30%2 | 50%2 |
| Physical, Occupational, Chiropractic Services, and Speech Therapy Plan covers up to 24 visits per year. |
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30%2 | 50%2 |
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30%2 | 50%2 |
| Durable Medical Equipment Up to a maximum of $5,000 per calendar year, in and out-of-network combined. |
30%2 | 50%2 |
| Oxygen | 30%2 | 50%2 |
| Organ Transplants | 30%2 | 50%2 |
| Home Health Care Limited to 60 visits per member in each benefit year, in and out-of-network combined. |
30%2 | 50%2 |
| Hospice Care Anthem will cover up to $100 per day for routine home care services, in- and out-of-network combined. |
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30%2 | 50%2 |
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30% | 50% |
| Skilled Nursing Facility Care Benefits are limited to 100 days per member per year, in and out-of-network combined. |
30%2 | 50%2 |
| Dental Care | Not Covered | |
| Vision Care | Not Covered | |
| Outpatient Prescription Drug Benefit | In-Network You Pay | Out-of-Network You Pay |
| Choice of either Comprehensive Prescription Drug Coverage or Generic Prescription Drug Coverage Only | ||
| Generic Prescription Drug Coverage | ||
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$15 co-payment or 40% coinsurance for Generic Coverage ONLY, whichever is greater | Not Covered |
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While this plan does not cover brand-name drugs, members who wish to purchase them can do so and will receive Anthem-negotiated savings if obtained from an in-network retail pharmacy. | Not Covered |
| Comprehensive Prescription Drug Coverage | ||
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$15 co-payment or 40% coinsurance, whichever is greater | Not Covered |
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$500 annual deductible applies before the following: Brand-name: $15 copay (or 40%, whichever is greater, not to exceed $500 per prescription). Speciality: 40% |
Not Covered |
| Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility. | ||
| 1Excludes non-participating charges in excess of the Anthem negotiated fee and non-participating charges in excess of customary and reasonable fees. Copayments and coinsurance amounts apply to the annual calendar year out-of-pocket maximum except where specifically noted in the policy. 2Services subject to calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other. 3If you receive services from a non-participating provider, you will pay the coinsurance plus any difference between our Maximum Benefit Amount (MBA) and the provider's billed charges. |
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| Anthem PPO Network These plans are available with Anthem PPO network. To find a doctor or local hospital, visit www.anthem.com and select the "Find a Doctor" button for a complete list of providers within the network. Brief Outline of Coverage This Anthem SmartSense Benefits Overview is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the contract or certificate of coverage. In the event of a conflict between the contract or certificate of coverage and this Anthem SmartSense Benefits Overview, the terms of the contract or certificate of coverage will prevail. |
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| READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! |