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Individual & Family Medical, Dental & Life Plans
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Great News!!!
Our Individual Plan Portfolio is now complete! New Plans to fit all your clients
needs.
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New PPACA compliant plans !!!!
Anthem Blue Cross Life & Health Insurance PoliciesSmartSense Plus ClearProtection PlusCoreGuard PlusLumenos HSA PlusPremier PlusTonik 5000
Anthem Blue Cross PlansPPO Share
HMOs
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Quick Review of PPACA Mandates
• Unlimited Lifetime Maximum• Dependents to Age 26• Rescission Reform• Removal of Dollar limits on Essential Health Benefits
• In Network Preventive Covered at 100%• No Pre-existing for children under age 19
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Grandfathered vs Non-Grandfathered
Grandfathered members enrolled with an effective date on or before 03/23/10
Non-Grandfathered members enrolled with an effective date between 03/24/10 and 09/22/10
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Preventive Care SummaryAdult Preventive Care
Office Visits Screening Tests including the following: Vision screening Hearing screening Cholesterol and Lipid level screening Blood Glucose test to screen for Type II Diabetes Prostate Cancer screenings including Digital Rectal Exam and PSA test Breast exam and Mammography screening Pelvic exam, Pap test and contraceptive management for females Screening for sexually transmitted diseases HIV test Bone Density test to screen for osteoporosis Colorectal Cancer screening including Fecal Occult Blood test, Barium Enema, Flexible Sigmoidoscopy and screening Colonoscopy Routine blood and urine screenings
Immunizations Hepatitis A Hepatitis B Tetanus, Diphtheria (Td) Varicella (chicken pox) Influenza (flu shot) Pneumococcal Conjugate (pneumonia) Human Papilloma Virus (HPV) Measles, Mumps, Rubella (MMR) Meningococcal Polysaccharide Herpes Zoster (shingles)
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Preventive Care Summary Cont. Well Baby and Well Child Preventive Care
Office Visits Screening Tests including the following: Vision screening Hearing screening Screening for lead exposure Pelvic exam, Pap test and contraceptive management for females
Immunizations Hepatitis A Hepatitis B Diphtheria, Tetanus, Pertussis (DtaP) Varicella (chicken pox) Influenza (flu shot) Pneumococcal Conjugate (pneumonia) Human Papilloma Virus (HPV) H. Influenza type b Polio Measles, Mumps, Rubella (MMR) Meningococcal Polysaccharide Rotavirus
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Deductible Options
Three options!
2- member maximum Once 2 members each reach the deductible, the deductible is satisfied
for the entire family. (Share PPO, HMO Plans)
Aggregate When one or more family members’ eligible covered expenses
(combined) meet the aggregate amount, the requirement is satisfied for all covered family members. (Lumenos HSA)
Embedded deductible The family deductible can be satisfied by 2 or more family members.
(Premier Plus, SmartSense Plus, CoreGuard Plus, ClearProtection Plus)
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Policy/Plan Terms Network Discounts- Negotiated costs between Anthem Blue Cross and
our participating providers. Coinsurance- The percentage of the cost of covered services that the
member is responsible for, after the annual deductible has been met. Deductible- The amount you have to pay each calendar year for covered
services before your health plan starts paying. Out-Of-Pocket Maximum- The most that you would have to pay in a
calendar year for deductible and coinsurance for in-network covered services.
Formulary- a list of prescription drugs our health plans cover. Specialty Drugs- typically high in cost, scientifically engineered drugs
used to treat complex, chronic conditions. Health Savings Account (HSA) – is a special bank account that can be
set up by a member enrolled in a qualified HSA-compatible high-deductible health plan if they choose. Contributions to this account can be made with certain tax advantages if used for qualified health care expenses.
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Find a plan that meets your clients needs
You can achieve this by simply asking the following questions to your client:
PPO or HMO? Are you looking for maternity coverage? What type of prescription coverage are you looking for?
Generic? Name brand? What does your budget look like? Are you looking for coverage that is comparable to group?
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Things to keep in mind
Maternity and Pharmacy are the main cost drivers on
each plan. The higher the deductible option, the lower the premium. If coming off of group coverage, enrollment under Individual
is medically underwritten. To increase client retention always include a quote for dental
and life products. Social security numbers are not needed to apply, only
California residency for at least 3 months. The earliest effective date available would be 15 calendar
days after receipt of the application. Writeable Applications can now be emailed to
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“What are the plans that Anthem Blue Cross has to offer?”
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PPO Policies/Plans
Premier Plus SmartSense Plus ClearProtection Plus CoreGuard Plus Lumenos HSA Lumenos HSA Plus Tonik 5000 PPO Share
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Premier Plus
Six deductible options from a $1000-$6000 Unlimited - First dollar (no deductible) office visits with
separate office visit copays for family practice and specialist ($30 & $50)
Routine vision exam 100% Preventive Care Coverage Comprehensive drug coverage from generics to
specialty drugs “Embedded” family deductible and out-of-pocket
maximum
No maternity coverage
Benefits shown are in-network
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Premier PlusAnnual Out-of-Pocket Maximum
Single/Family (in addition to deductible)
$4,500/$9,000
(family out of pocket can be satisfied by 2 or more members)
Annual Deductible
(embedded deductible)
$1,000, $1,500, $2,500, $3,500, $5,000, $6,000 (single)
$2,000, $3,000, $5,000, $7,000, $10,000, $12,000 (family)
(family deductible can be satisfied by 2 or more members)
Office Visits
(Deductible waived)
$30 copay for primary care physician; $50 copay for specialist (Deductible waived)
Preventive CareIncludes all nationally recommended preventive services including well-child care,
immunizations, PSA screenings , PAP tests, mammograms and more.
0% Coinsurance, not subject to deductible
Professional/Diagnostic Services
(x-ray, lab, anesthesia, surgeon, etc.)25% after the deductible
Inpatient/ Outpatient Services 25% after the deductible
Maternity Not covered
Drug Benefits
(Premier uses the Anthem Blue Cross formulary & has the same benefits as SmartSense with Upgrade RX)
Tier1: (Generic drugs) $15 copay
$500 annual Prescription Drug deductible per member applies before the following:
Tier2: (Formulary Brand name drugs) $40 copay
Tier3 : (Non-Formulary Brand name drugs) $60 copay Specialty:25% Coinsurance up to a $2,500 Annual OOP Max (the most you’ll have to pay),
in-network only and in addition to $500 annual deductible
Routine Vision Exam $20 copay (deductible waived) for vision exam only
Benefits shown are in-network
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SmartSense Plus
Choice of 4 new deductibles
Choice of standard or upgrade drug coverage
“Embedded” family deductible and out-of-pocket maximum
3 office visits before deductible
No maternity coverage
100% Preventive care
Benefits shown are in-network
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Annual Out-of-Pocket Maximum Single/Family (in addition to deductible)
$3,500/$7,000
Annual Deductible$1,000, $2,000, $3,500 or $6,000 (single)
$2,000, $4,000, $7,000 or $12,000 (family)
Office Visits 3 before deductible w/ $30 copay, then 30% after deductible
Preventive Care
Includes all nationally recommended preventive services including well-child care, immunizations, PSA screenings , PAP tests, mammograms and
more.
0% Coinsurance, not subject to deductible
Hospital In/Outpatient 30% after deductible
Drug Benefits Standard
Upgrade
Generic: $15 copay
Brand/Specialty: $7,500 annual brand deductible per member, then: $40 copay (formulary brand), $60 copay (non-formulary brand), Specialty 25% up to $2,500 annual OOP max. (plus $7,500 deductible)
Generic: $15 copay
Brand/Specialty: $500 annual brand deductible per member, then: $40 copay (formulary brand), $60 copay (non-formulary brand), Specialty 25% up to $2,500 annual OOP max. (plus $500 deductible)
Maternity Not covered
SmartSense Plus
Benefits shown are in-network
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Lumenos HSA Plus
Consumer-Driven Health Plans (CDHPs) HSA-compatible 100% coverage after deductible Preventive care benefits Various deductible options Special programs for Smoking Cessation and Weight
Management Powerful online health management tools
Access to our 24-Hour nurse Line
Benefits shown are in-network
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HSA Account Funded by subscriber, up to maximum limit set by U.S. Treasury Unused dollars rollover year-to-year Subscriber “owns” HSA
Annual Out-of-Pocket Maximum (in addition to deductible)
0%
Annual DeductibleSingle: $3,000/$4,500/$5,950
Family: $3,500/ $5,500 (Aggregate Deductible) orFamily: $7,500/$11,900 (Embedded Deductible)
Coinsurance after deductible
0%
Office Visits 0%
Preventive Care (nationally recommended services)
$0 (deductible waived)
Hospital In/ Outpatient 0%
Maternity Not covered
Drug Benefits 0%
Lumenos HSA Plus
Benefits shown are in-network
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Lumenos HSA Plus Examples – 2 members on policy
Lumenos HSA Plus $3500 (aggregate)
• Husband meets $1750
• After wife meets other $1750, they both are covered at 100%
• Family deductible can also be met by just one family member (example once husband meets $3500 both him and his wife will be covered 100%)
Lumenos HSA Plus $7500 (embedded)
• Husband meets $3750 (half of the family deductible) then he is covered 100%
• After wife meets the additional $3750, she gets covered 100%
***Please note examples given are based on In-Network benefits
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HSA Account
Funded by subscriber, up to maximum limit set by U.S. Treasury Unused dollars rollover year-to-year Subscriber “owns” HSA
Annual Out-of-Pocket Maximum/Member (in addition to deductible)
$3,500 (single)$7,000 (family)
Annual Deductible$1,500 (single)
$3,000 (family maximum)
Coinsurance after deductible
30%
Office Visits 30% after deductible
Preventive Care (nationally recommended services)
0% (deductible waived)
Hospital In/ Outpatient 30% after deductible
Maternity Not covered
Drug Benefits 30% after deductible
Lumenos Health Savings Account (HSA)-Compatible
Benefits shown are in-network
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HSA Account
Funded by subscriber, up to maximum limit set by U.S. Treasury Unused dollars rollover year-to-year Subscriber “owns” HSA
Annual Out-of-Pocket Maximum/Member (in addition to deductible)
$0
Annual Deductible$5,000 (single)
$10,000 (family maximum)
Coinsurance after deductible
0%
Office Visits 0% after deductible
Preventive Care (nationally recommended services)
0% (deductible waived)
Hospital In/ Outpatient 0% after deductible
Maternity 0% after deductible
Drug Benefits 0% after deductible
Lumenos Health Savings Account (HSA)-Compatible With Maternity
Benefits shown are in-network
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CoreGuard Plus
Higher percentage of member cost sharing in exchange for lower premiums
Choice of 7 deductibles
Full drug coverage
“Embedded” family deductible and out-of-pocket maximum
No maternity coverage
Inpatient/outpatient facility copays for 3 lowest deductibles
Separate in-network and out-of-network deductibles and out-of-pocket maximums
Benefits shown are in-network
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Annual Out-of-Pocket Maximum Single/Family (in addition to deductible)
$3,500/$7,000/$0 (for $10,000 single/$20,000 family)
Annual Deductible$750, $1,500, $2,500, $3,500, $5,000, $7,500, $10,000 (single)
$1,500, $3,000, $5,000, $7,000, $10,000, $15,000, $20,000 (family)
Office Visits 50% after deductible (0% for $10,000 plan)
Preventive Care
Includes all nationally recommended preventive services including well-child care, immunizations, PSA screenings , PAP tests, mammograms and
more.
0% Coinsurance, not subject to deductible
Inpatient/Outpatient50% after deductible (0% for $10,000 plan) plus:
For $750/$1500/$2500 plans: $500 inpatient facility copay for first 3 days, $200 outpatient facility copay per admission
Drug Benefits Generic: $15 copay
Brand name: $7500 annual brand deductible per member, then:$40 copay for brand name; $60 copay
non-formulary
25% coinsurance for specialty up to $2500 annual drug out-of-pocket maximum in addition to $7500 deductible
Maternity Not covered
CoreGuard Plus
Benefits shown are in-network
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ClearProtection Plus
Two deductible levels (negotiated rates apply before and after meeting deductible) Lower deductible for Inpatient/Outpatient Surgical and Emergency Room
Higher deductible for Outpatient/Professional/Diagnostic (this deductible is equal to the plan out-of-pocket maximum)
Two deductibles work together to meet out-of-pocket maximum
2 office visits before deductible
Full drug coverage
“Embedded” family deductible and out-of-pocket maximum
No maternity coverage
Coverage for generic and brand name prescription drugs
Benefits shown are in-network
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Annual Out-of-Pocket Maximum (including deductible)
$4,500/$6,800/$8,500 (single)
$9,000/$13,600/$17,000 (family)
Annual Deductible (inpatient/Outpatient Surgical/ER)
$1,000, $3,300 or $5,000 (single)
$2,000, $6,600, or $10,000 (family)
Annual Deductible (outpatient/professional/diagnostic)
$4,500/$6,800/$8,500 (single)
$9,000/$13,600/$17,000 (family)
Office Visits 2 before deductible w/ $40 copay, then 0% after out-of-pocket met
Preventive CareIncludes all nationally recommended preventive services including well-child
care, immunizations, PSA screenings , PAP tests, mammograms and more.
0% Coinsurance, not subject to deductible
Inpatient/OutpatientInpatient/Outpatient Surgical/ER: 40% after deductible
Outpatient professional/diagnostic services: 0% after out-of-pocket met
Drug Benefits Generic: $15 copay
Brand name: $7500 annual brand deductible per member, then: $40 copay for brand name; $60
copay non-formulary
25% coinsurance for specialty up to $2500 annual drug out-of-pocket maximum in addition to
$7500 deductible
Maternity Not covered
ClearProtection Plus
Benefits shown are in-network
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Tonik
Lowest out of pocket maximum 100% coverage after deductible/
out of pocket have been met Built in dental and vision benefits 100% preventive care coverage Non maternity coverage Generic prescription coverage $15 copay
Benefits shown are in-network
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Annual Out-of-Pocket Maximum/Member (in addition to deductible)
$0
Annual Deductible $5,000
Coinsurance after deductible
0%
Office Visits $20 copay/first 4 visits, then 0% after deductible
Preventive Care (nationally recommended services)
$0 (deductible waived)
Hospital In/ Outpatient $0 after deductible
Maternity Not covered
Dental $0 for cleanings, exams, and X-rays
Vision$25 for basic eyeglass lenses and receive up to $100 towards
frames or $80 towards contact lenses every 24 months
Drug Benefits $15 for a 30-day supply
Tonik 5000
Benefits shown are in-network
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PPO Plans
Comprehensive PPO plans
Once deductible is met, member pays 0% or 30% co-insurance (depending on plan) for most covered services
Deductible waived for office visits, annual physical exam and preventive care
Maternity coverage
Generic and Brand name prescription coverage
PPO Share (7500/5000/3500)
Benefits shown are in-network
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7500 5000 3500Annual Out-of-Pocket Maximum (in addition to deductible)(2-member maximum, par/non-par)
$0 per member
$2,500 per member
$4,000 per member
Annual Deductible
(2-member maximum)$7,500
per member$5,000
per member $3,500
per member
Office Visits$40 copay
deductible waived
$40 copay
deductible waived
$40 copay
deductible waived
Preventive Care
(deductible waived)
Includes all nationally recommended preventive services including well-child care, immunizations, PSA screenings , PAP tests, mammograms and more.
0% Coinsurance, not subject to deductible
Hospital In/ Outpatient 30% of negotiated fee or 0% (with 7,500 deductible plan)
Maternity 30% of negotiated fee or 0% (with 7,500 deductible plan)
Drug Benefits (Anthem Blue Cross Formulary) (2-member maximum for brand deductible)
$15 generic or 40% which ever is greater;
$15 brand copay or 40% which ever is greater after $750 brand deductible
$15 generic;
$35 brand copay after $750 brand deductible
$15 generic or 40% which ever is greater;
$15 brand copay or 40% which ever is greater after $750 brand deductible
PPO Share (7500/5000/3500)
Benefits shown are in-network
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HMO Plans
HMO Saver
Individual HMO
Select HMO
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HMO Plans
First dollar coverage on: Office visits Generic drugs Preventive care
Unlimited office visits with set copays
Coverage for services from doctors and hospitals in HMO network
Comprehensive drug plan
Maternity coverage
HMO Saver, Individual HMO, Select HMO
Benefits shown are in-network
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HMO PlansHMO Saver Individual HMO Select HMO
Annual Out-of-Pocket Maximum(in addition to deductible)
$1500/member
(2-member maximum)
$3,000/member
(2-member maximum)
Annual Deductible $1,500/member for Inpatient, Outpatient and
ASCs onlyNo deductible
Office Visits (unlimited) $10 copay/visit $25 copay/visit
Preventive Care 0% Coinsurance, not subject to deductible0% Coinsurance
Hospital In/Outpatient $1,500 deductible, then:
Inpatient: 20% of negotiated fee
Outpatient: 20% of negotiated fee (emergency & non-emergency services subject to deductible)
Inpatient: 20% of negotiated fee
Outpatient: 20% of negotiated fee
Inpatient: $250 copay/day first 4 days; then covered at 100%
Outpatient: 20% of negotiated fee,$250/surgery
Maternity Office visits: $10 copay
Inpatient/Outpatient: 20% of negotiated fee, after
deductible
Office visits: $10 copay
Inpatient/Outpatient: 20% of negotiated fee,
after deductible
Office Visits: $25 copay
Inpatient: $250 copay per day up to the first 4 days, then 0% per admission
Drug Benefits (Anthem Blue Cross formulary)
$10 generic; $30 brand copay after $250 brand deductible (2-member maximum)
Benefits shown are in-network
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Plan Options Based on Prospect’s Needs
If Main Need Is: Recommended Plans:
BudgetTonik 5000, Premier PPO, ClearProtection Plus, CoreGuard Plus
Immediate coverage for office visits before deductible
PPO Share and HMO (unlimited) Tonik 5000 (4 visits before deductible)
Premier Plus (unlimited)
ClearProtection Plus (2 visits before deductible)
SmartSense Plus (3 visits before deductible)
No deductible Individual HMO or Select HMO
100% coverage of most services after deductible
Lumenos HSA 5000
Lumenos HSA plus
Tonik 5000
CoreGuard Plus 10,000
Control over finances, including health care expenses
Lumenos HSA
Lumenos HSA Plus
Maternity coverageLumenos with maternityPPO ShareHMO
Benefits shown are in-network
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Short-Term Plans
Coverage from 30 to 180 days
Choice of deductible level
Easy application process
Streamlined underwriting
No maternity
Member-level-rated
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Out-of-Pocket Maximum $1,000 per member plus deductible
Deductible $250, $500, $1,000, $2,000
Hospital In/Outpatient 20% of negotiated fee
Ambulatory Surgical Center and ER
20% of negotiated fee
(Accidental injuries not subject to deductible)
Maternity Not covered
Drug Benefits (Anthem Blue Cross Formulary)
$10 generic; $30 brand name
Brand name maximum $500
Short-Term Plans
Benefits shown are in-network
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Three Individual dental options:
Dental Blue Basic* Dental Blue Enhanced*Dental SelectHMO**
•*Anthem Blue Cross Life & Health Insurance Company
•**Anthem Blue Cross
Dental Plans
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Dental Plans
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Dental SelectHMO
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Individual Life Insurance
Anyone who qualifies for one of medical plans can purchase: $15,000, $30,000, $50,000, $75,000 or $100,000 (if over age 19) $15,000 or $30,000 (ages 1-19)
Term Life Insurance
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Health • Dental • Life
Thank You for Selling Anthem Blue Cross!