Individual & Family Medical, Dental & Life Plans.

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

[email protected]

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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


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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


100% Preventive care


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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.


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)


SmartSense Plus


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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


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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%


Drug Benefits 0%

Lumenos HSA Plus


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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)


30%

Office Visits 30% after deductible


0% (deductible waived)

Hospital In/ Outpatient 30% after deductible


Drug Benefits 30% after deductible

Lumenos Health Savings Account (HSA)-Compatible


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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


$0

Annual Deductible$5,000 (single)

$10,000 (family maximum)


0%

Office Visits 0% after deductible


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


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CoreGuard Plus

Higher percentage of member cost sharing in exchange for lower premiums

Choice of 7 deductibles

Full drug coverage



Inpatient/outpatient facility copays for 3 lowest deductibles

Separate in-network and out-of-network deductibles and out-of-pocket maximums


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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.


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


CoreGuard Plus


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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



Coverage for generic and brand name prescription drugs


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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.


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


ClearProtection Plus


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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


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$0

Annual Deductible $5,000


0%

Office Visits $20 copay/first 4 visits, then 0% after deductible


$0 (deductible waived)

Hospital In/ Outpatient $0 after deductible


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


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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)


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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.


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)


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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


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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)


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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


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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)


Drug Benefits (Anthem Blue Cross Formulary)

$10 generic; $30 brand name

Brand name maximum $500

Short-Term Plans


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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!

Individual & Family Medical, Dental & Life Plans.

Documents

Transcript of Individual & Family Medical, Dental & Life Plans.