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Individual & Family Medical, Dental & Life Policies/Plans for New Sales Benefits Effective July 1, 2012 The benefits of any particular plan or policy are.

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Presentation on theme: "Individual & Family Medical, Dental & Life Policies/Plans for New Sales Benefits Effective July 1, 2012 The benefits of any particular plan or policy are."— Presentation transcript:

1 Individual & Family Medical, Dental & Life Policies/Plans for New Sales Benefits Effective July 1, 2012 The benefits of any particular plan or policy are subject to change. This presentation is a summary only and does not list all benefits, exclusions and limitations. The evidence of coverage or policy should be consulted for a detailed description of benefits and limitations. If there is any difference between this presentation and a plan/policy, the provisions of the plan/policy will prevail.

2 2 Policies and Plans Anthem Blue Cross Life & Health Insurance Company Policies  Premier Plus  SmartSense Plus  ClearProtection Plus 3300  CoreGuard Plus  Lumenos HSA Plus  Tonik 5000 Anthem Blue Cross Plans  PPO Share  HMOs

3 3 Deductible Options Three deductible options!  Embedded  The family deductible can be satisfied by 2 or more family members. (Premier Plus, SmartSense Plus, CoreGuard Plus, ClearProtection Plus, some Lumenos HSA Plus deductibles)  Aggregate  When one or more family members’ eligible covered expenses (combined) meet the aggregate amount, the deductible is satisfied for all covered family members. (Lumenos HSA, some Lumenos HSA Plus deductibles)  2- Member Maximum  Once 2 members each reach the deductible, the deductible is satisfied for the entire family. (Share PPO, HMO Plans)

4 4 Policy/Plan Terms  Network Discounts- Negotiated costs between Anthem 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 member pays each calendar year for covered services before their health plan starts paying.  Out-Of-Pocket Maximum- The most that member 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. There can be different formularies for different health care plans.  Specialty Drugs- typically high in cost, scientifically engineered drugs used to treat complex, chronic conditions.  Health Savings Account (HSA) – 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.

5 5 Find a plan that meets your clients needs You can achieve this by simply asking the following questions to your client:  PPO or HMO?  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?

6 6 Things to keep in mind  Pharmacy is a major cost driver on each plan.  The higher the deductible option within a plan family, the lower the premium.  If coming off of group coverage, enrollment under Individual is medically underwritten (except for HIPAA guarantee issue policies/plans).  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 is 15 calendar days after receipt of the application.

7 7 PPO Policies/Plans  Premier Plus  SmartSense Plus  ClearProtection Plus 3300  CoreGuard Plus  Lumenos HSA Plus  Tonik 5000  PPO Share

8 8 Premier Plus  6 deductible options from $1000-$6000  “Embedded” family deductible and out-of-pocket maximum  Unlimited number of office visits before deductible - separate office visit copays for family practice ($30) and specialist ($50)  100% preventive care coverage  Comprehensive drug coverage  Maternity coverage  Routine vision exam Benefits shown are in-network

9 9 Premier Plus Annual 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 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 Professional/Diagnostic Services (x-ray, lab, anesthesia, surgeon, etc.) 25% after the deductible Inpatient/ Outpatient Services25% after the deductible MaternityCovered as other services above Drug BenefitsTier1: (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

10 10 SmartSense Plus  3 deductible options from $2000-$6000  “Embedded” family deductible and out-of-pocket maximum  3 office visits with $30 copay before deductible  100% preventive care coverage  Choice of standard or upgrade drug coverage  Maternity coverage Benefits shown are in-network

11 11 Annual Out-of-Pocket Maximum Single/Family (in addition to deductible) $3,500/$7,000 Annual Deductible $2,000, $3,500 or $6,000 (single) $4,000, $7,000 or $12,000 (family) Office Visits3 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/Outpatient30% 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) MaternityCovered as other services above SmartSense Plus Benefits shown are in-network

12 12 ClearProtection Plus 3300  Two deductibles work together to meet out-of-pocket maximum:  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)  “Embedded” family deductible and out-of-pocket maximum  2 office visits with $40 copay before deductible  100% preventive care coverage  Comprehensive drug coverage ( $7500 brand/specialty drug deductible)  Maternity coverage  In-network and out-of-network deductibles are combined and accumulate toward each other. In-network and out-of-network out-of-pocket maximums are also combined and accumulate toward each other.  Benefits shown are in-network

13 13 ClearProtection Plus 3300 How the Two Deductibles Work Benefits shown are in-network #1Meet Inpatient-Surgical deductible plus coinsurance (e.g.,hospitalization) #2 Meet Outpatient-Professional deductible (e.g. office visits, outpatient lab work) #1 Meet Inpatient/Surgical deductible plus coinsurance (e.g., hospitalization) #2 Meet Outpatient/Professional deductible (e.g., office visits, outpatient lab work) Or any combination of #1 and #2 Total out-of-pocket maximum equals: $6,800(single)/$13,600(family)

14 14 Annual Out-of-Pocket Maximum (including deductible) $6,800 (single) $13,600 (family) Annual Deductible (inpatient/Outpatient Surgical/ER) $3,300 (single) $6,600 (family) Annual Deductible (outpatient/professional/diagnostic) $6,800 (single) $13,600 (family) Office Visits2 before deductible w/ $40 copay, then 0% after out-of-pocket met 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/Outpatient Inpatient/Outpatient Surgical/ER: 40% after deductible Outpatient professional/diagnostic services: 0% after out-of-pocket met Drug BenefitsGeneric: $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 MaternityCovered as other services above ClearProtection Plus 3300 Benefits shown are in-network

15 15 CoreGuard Plus  5 deductible options from $750-$5000  “Embedded” family deductible and out-of-pocket maximum  Office visits – 50% coinsurance after deductible  100% preventive care coverage  Comprehensive drug coverage ($7500 brand/specialty drug deductible)  Maternity coverage  Higher percentage of member cost sharing in exchange for lower premiums  Inpatient/outpatient facility copays for 3 lowest deductibles Benefits shown are in-network

16 16 Annual Out-of-Pocket Maximum Single/Family (in addition to deductible) $3,500/$7,000 Annual Deductible $750, $1,500, $2,500, $3,500, $5,000 (single) $1,500, $3,000, $5,000, $7,000, $10,000 (family) Office Visits50% 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 Inpatient/Outpatient 50% after deductible plus: For $750/$1500/$2500 plans: $500 inpatient facility copay for first 3 days, $200 outpatient facility copay per admission Drug BenefitsGeneric: $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 MaternityCovered as other services above CoreGuard Plus Benefits shown are in-network

17 17 Lumenos HSA Plus  Aggregate or embedded family deductible options  Office visits – 0% coinsurance after deductible  100% preventive care coverage  Comprehensive drug coverage (combined medical/RX deductible)  Maternity coverage  HSA-compatible  100% coverage after deductible  Special programs for Smoking Cessation and Weight Management, 24-hour nurse line, online health management tools Benefits shown are in-network

18 18 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 Deductible Single: $5,950 Family: $5,500 (Aggregate Deductible) or Family: $7,500/$11,900 (Embedded Deductible) Coinsurance after deductible 0% Office Visits0% Preventive Care (nationally recommended services) $0 (deductible waived) Hospital In/ Outpatient0% MaternityCovered as other services above Drug Benefits0% Lumenos HSA Plus Benefits shown are in-network

19 19 Lumenos HSA Plus Examples 2 Members on Policy Lumenos HSA Plus $5500 (aggregate) Husband meets $2750 After wife meets other $2750, they both are covered at 100% Family deductible can also be met by just one family member (example once husband meets $5500 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% Examples are based on in-network benefits

20 20 Tonik 5000  4 office visits with $20 copay before deductible  100% preventive care coverage  Generic-only drug coverage  Maternity coverage  Built in dental and vision benefits  Tonik members can purchase Enhanced Tonik Dental plan Benefits shown are in-network

21 21 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 MaternityCovered as other services above Dental $0 for cleanings, exams, and X-rays (Enhanced Tonik Dental available) 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

22 22 Enhanced Tonik Dental Available to Tonik Members Only

23 23 PPO Share  Three deductible options from $3500-$7500  2-member maximum deductible and out-of-pocket maximum  Unlimited number of office visits with $40 copay before deductible  100% preventive care coverage  Comprehensive drug coverage  Maternity coverage  Once deductible is met on $7500 plan, member pays 0% co-insurance for most covered services Benefits shown are in-network

24 Annual 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/ Outpatient30% of negotiated fee or 0% (with 7,500 deductible plan) Maternity30% 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

25 25 HMO Plans  HMO Saver  Individual HMO  Select HMO

26 26 HMO Plans  Deductible and no-deductible options  2-member maximum deductible and out-of-pocket maximum  Unlimited number of office visits with $10 or $25 copay depending on plan  100% preventive care coverage  Comprehensive drug coverage  Maternity coverage  Coverage for services from doctors and hospitals in HMO network Benefits shown are in-network

27 27 HMO Plans HMO SaverIndividual HMOSelect 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 only No 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 MaternityOffice 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

28 28 Options Based on Prospect’s Needs If Main Need Is:Recommended Policies/Plans: BudgetClearProtection Plus 3300, CoreGuard Plus Immediate coverage for office visits before deductible All open policies/plans come with 100% Preventive Care (in- network) prior to deductible, and all provide members unlimited office visits (see plan benefit grids for details). Most include office visits at a copay, before deductible: Premier Plus, PPO Share (unlimited number) Tonik 5000 (4) SmartSense Plus (3 ) ClearProtection Plus 3300 (2) Low deductibleCoreGuard Plus 750, Premier Plus % coverage of most services after deductible Lumenos HSA Plus Tonik 5000 PPO Share 7500 Control over finances, including health care expenses Lumenos HSA Plus Benefits shown are in-network

29 29 Three Individual dental options:  Dental Blue Basic*  Dental Blue Enhanced*  Dental SelectHMO** *Anthem Blue Cross Life & Health Insurance Company **Anthem Blue Cross Dental Policies/Plans

30 30 Dental Blue

31 31 Dental SelectHMO

32 32 Individual Term Life Insurance  Anyone who qualifies for a medical policy/plan 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)

33 33 Health Dental Life Thank You for Selling Anthem Blue Cross!

34 34 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.


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