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New Blue Cross Smart Sense PPO |
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| If
you have any questions, please call (818)
654-4548 |
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| Enrollment
Applications & forms |
Blue Cross Smart Sense PPO Plan
Highlights |
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Blue Cross Smart Sense Benefits |
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IN-NETWORK |
OUT-OF-NETWORK |
Annual
Deductible Choices
(choose from 4 low-cost plans) |
$500/$1000;
$1,500/$3,000
$2,500/$5,000;
$5,000/$10,000 |
Single
member $5,000
Family maximum $10,000 |
Lifetime
Maximum |
$7,000,000 |
Annual
Out-of-Pocket Max.
(In addition to deductible) |
Single
member $2,500
Family maximum $5,000 |
Single
member $10,000
Family maximum $20,000 |
Doctors'
Office Visits |
30%
copay for first three visits
per member per year (deductible
waived) and once deductible
is met, then 30% of negotiated
fee |
50%
of negotiated fee plus all
excess charges |
Professional
Services
(X-ray,lab,anesthesia,surgeon,etc.) |
30%
of negotiated fee |
50%
of negotiated fee plus all excess
charges |
Hospital
Inpatient
(Overnight Hospital Stays) |
30%
of negotiated fee |
All
Charges except $650 per day |
Hospital
Inpatient
(If You Don't Stay Overnight) |
30% of negotiated
fee |
All Charges except
$380 per day |
| Emergency
Room Services |
30%
of negotiated fee |
50%
of customary and reasonable
fees plus excess charges |
| Maternity |
Not
covered |
| Preventive
Care |
Annual
physical exam(s): 30% of negotiated
fee
Routine mmammogram, Pap and
PSA tests: 30% of negotiated
fee
Well Baby and Well Child
(through age 6): 30% of negotiated
fee |
Annual
phyical exam(s): 50% of negotiated
fee plus all exess charges
Routine mammogram, Pap and
PSA tests: 50% of negotiated
fee plus all excess charges
Well Baby and Well Child
(through age 6): 50% of negotieated
fee plus all excess charges
< td> |
| Ambulance |
30%
of negotiated fee |
50%
of negotiated fee plus excess
charges |
| Physical/Occupational/Speech
Therapy; Chiropractic Services |
30%
of negotiated fee
Plan pays up to $2,500 per year
for therapy and up to $500 per
year for chiropractic services |
50%
of negotiated fee
plus all excess charges
Plan pays up to $2,500 per year
for therapy and up to $500 per
year for chiropractic services |
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Prescription Drug Coverage Options |
IN-NETWORK |
OUT-OF-NETWORK |
| SmartSense
with Generic Prescription Drug
Coverage (Drugs on Generic Rx
Formulary only) |
Generic:
$15 copay (or 40%, whichever
is greater) |
Generic:
$15 copay (or 40%, whichever
is greater) |
| SmartSense
with Comprehensive Prescription
Drug Coverage (Blue Cross Formulary
Drugs) |
Generic:
$15 copay (or 40%, whichever
is greater)
$500 annual brand-name/specialty
drug deductible (2 member
maximum) applies before the
following:
Brand-name: $15 copay (or
40%, whichever is greater);
40% of negotiated fee for
self-administered injectables,
except insulin
Specialty: 40%
$4,500 annual out-of-pocket
maximum (the most you will
have to pay)
(in-network only and in addition
to brand-name/specialty drug
deductible) |
Generic:
$15 copay (or 40%, whichever
is greater)
$500 annual brand-name/specialty
drug deductible applies before
the following:
Brand-name: $15 copay (or
40%, whichever is greater);
40% of negotiated fee for
self-administered injectables,
except insulin
Specialty: not |
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| Blue Cross Smart Sense PPO |
What else do you get?
• Access to over 50,000 California
PPO network doctors and specialists 400
hospitals – so chances are your doctor
is one of ours
• Money in your
pocket – because we’ve negotiated
lower fees with doctors and hospitals, your
share of costs is less (a lot less)
• Free health and wellness programs
– designed to keep you as healthy
• Out-of-state coverage – so
you’ll feel better wherever you are |
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Is SmartSense for you? |
• Reliable, basic protection with
some of our lowest monthly rates
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Choose the annual deductible/monthly rate
combination that works for you
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Immediate benefits for first three visits
to a doctor
• Choice of prescription
drug benefits (Comprehensive Rx or Generic
Only Rx)
• No need for maternity
benefits
• Health plan pays up
to $7,000,000 per member in lifetime benefits |
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Waiting Periods
There is a specific six-month waiting period
for coverage of any condition, disease or
ailment for which medical advice
or treatment was recommended or received
within six months preceding the effective
date of coverage. If you apply
for coverage within 63 days of terminating
your membership with another “creditable”
health care plan, then you
can use your prior coverage for credit toward
the six-month waiting period. Blue Cross
will credit the time you were
enrolled in the previous plan. Consult with
your Blue Cross agent or representative
if you have a question about the
underwriting process. |
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| Ready to Enroll?
Apply online now |
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No-Obligation Review Period
After you enroll in a plan offered by Blue
Cross of California or BC Life & Health
Insurance Company, you will receive
a Policy/EOC booklet that explains the exact
terms and conditions of coverage, including
the plan’s exclusions and
limitations. You have 10 full days to examine
your plan’s features. During that
time, if you are not fully satisfied,
you may decline by returning your Policy/EOC
booklet along with a letter notifying us
that you wish to discontinue
coverage. Policy/EOC booklets are available
for you to examine prior to enrolling. Ask
your agent or Blue Cross. |
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| New BC Life &
Health CORE 5000 , BC Life & Health Basic
PPO 1000 blue cross of california CORE 5000
blue cross SmartSense PPO
Blue Cross of California (BCC) and BC Life
& Health Insurance Company (BCL&H) are
Independent Licensees of the Blue Cross Association
(BCA). The Blue Cross name and symbol are registered
service marks of the BCA. The following plans
are offered by BCC: PPO Share 2500/1500/1000/500,
Individual HMO, HMO Saver, Select HMO, EPO and
Dental SelectHMO. The following plans are offered
by BCL&H: CORE 5000, Basic PPO 1000/2500,
PPO Saver, PPO Share 5000/1000/500, RightPlan
PPO 40, 3500 Deductible PPO, PPO 3500 (HSA-Compatible),
Short-Term PPO, Tonik, Individual PPO Dental
and Term Life
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Printable Application
Online Application