Anthem Blue Cross of California
SmartSense 1000 Plus Upgrade Rx Health Insurance Plan
A plan summary of the Anthem Blue Cross of California SmartSense 1000 Plus Upgrade Rx Plan is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
30% |
50% |
Office Visits |
$30 first 3 visits / member / year then 30% |
50% |
| Annual Deductible |
Individual: $1,000 Family: $2,000 |
Individual: $1,000 Family: $2,000 |
| Annual Out-Of-Pocket Limit |
Individual: $3,500 Family: $7,000 (Deductible not Included) |
Individual: $7,500 Family: $15,000 (Deductible not Included) |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Generic: $15
Brand: $40
Non-Formulary Brand : $60
($500 Brand Deductible, see brochure for details) |
Not Covered |
| Laboratory & X-Ray |
30% |
50% |
| Annual Physical Exam |
No Charge |
50% |
| Annual OB-GYN Exam |
No Charge |
50% |
Well Baby Care |
No Charge |
50% |
| Outpatient Surgery |
30% |
All Charges except $380/day after Deductible |
| Emergency Room |
30% plus $100 (Waived if admitted) |
30% plus $100 (Waived if admitted) |
| Inpatient Hospital |
30% |
All Charges Except $650/day after Deductible |
| Ambulance |
See Brochure |
See Brochure |
| Home Health Care |
See Brochure |
See Brochure |
| Mental Health - Outpatient |
See Brochure |
See Brochure |
| Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
See Brochure |
See Brochure |
| Mental Health - Inpatient |
See Brochure |
See Brochure |
| Chemical Dependency |
See Brochure |
See Brochure |
| Maternity Care |
Not Covered |
Not Covered |
To learn more about your
individual and family
California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
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