March 18, 2010

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Anthem – SmartSense Generic Only Rx 2500 – COLORADO

A comparison of the SmartSense Generic Only Rx 2500 offered by Anthem is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application SmartSense Generic Only Rx 2500 Application SmartSense Generic Only Rx 2500 Application
Brochure SmartSense Generic Only Rx 2500 Brochure SmartSense Generic Only Rx 2500 Brochure
Copay
  • Primary Care Providers- copayment per office visit when included in the first three office visits in a calendar year
  • Specialists- copayment per office visit when included in the first three office visits in a calendar year
    		•  50% after deductible
    Office Visit
  • Primary Care Providers- copayment per office visit when included in the first three office visits in a calendar year; then 70% after deductible
  • Specialists- copayment per office visit when included in the first three office visits in a calendar year; then 70% after deductible
    		•  50% after deductible
    Deductible $2,500 per individual, $5,000 maximum per family (once 2 or more members’ allowable charges that applied to their individual deductible, combine to equal the family maximum deductible) $5,000 per individual, $10,000 maximum per family (once 2 or more members’ allowable charges that applied to their individual deductible, combine to equal the family maximum deductible)
    Coinsurance 70% after deductible 50% after deductible
    Coinsurance Limit See OOP Maximum See OOP Maximum
    Out-of-Pocket Maximum
  • $5,000 per individual, includes deductible, copayments, and coinsurance.
  • $10,000 per family, includes deductible, copayments and coinsurance (Once 2 or more members’ allowable charges that applied to their individual out-of-pocket annual maximum, combine to equal the family out-of-pocket annual maximum)
    		•
  • $15,000 per individual, includes deductible, copayments, and coinsurance.
  • $30,000 per family, includes deductible, copayments and coinsurance (Once 2 or more members’ allowable charges that applied to their individual out-of-pocket annual maximum, combine to equal the family out-of-pocket annual maximum)
    		•
    Lifetime Maximum $7,000,000 per member $7,000,000 per member
    Prescription Drugs
  • Outpatient care:
    • Participating Retail Pharmacy:
      • Generic Drugs: $15 Copayment or 40% coinsurance, whichever is greater, for each prescription and/or refill for a maximum 30 day supply.
      • Generic Self-Administered Injectable Drugs: $15 Copayment or 40% coinsurance for each prescription and/or refill for a maximum 30 day supply.
  • Prescription Mail Service:
    • Mail Order:
        Generic Drugs: $15 Copayment or 40% coinsurance, whichever is greater for each prescription and/or refill for each 30 day supply or a $45 copayment or 40% coinsurance, whichever is greater, for up to a maximum 90 day supply.
      • Generic Self-Administered Injectable Drugs: $15 Copayment or 40% coinsurance for each prescription and/or refill for each 30 day supply, or a $45 copayment, or 40% coinsurance, whichever is greater, for up to a maximum 90 day supply for mail-order.
    		•  Not covered
    Emergency Room 70% after deductible 70% after deductible
    Adult Preventative Care $30 copayment per office visit when included in the first 3 office visits in a calendar year; then 70% after deductible for mammogram screening and prostate screening. Colorectal cancer screening is covered and is not subject to the deductible. 50% after deductible for age-appropriate visits and routine immunizations (up to age 13).
    Child Preventative Care $30 copayment per office visit when included in the first 3 office visits in a calendar year; then 70% after deductiblefor age-appropriate visits and routine immunizations (up to age 13). 50% after deductible for age-appropriate visits and routine immunizations (up to age 13).
    Lab / X-Ray 70% after deductible 50% after deductible
    Maternity Not covered except for complications of pregnancy. Not covered except for complications of pregnancy.
    Physical Therapy
  • Inpatient- 70% after deductible (up to 30 days per member in and out of network combined)
  • Outpatient- 70% after deductible (24 visits per calendar year for physical therapy, occupational therapy, and/or chiropractic therapy; in and out of network combined)
    		•
  • Inpatient- 50% after deductible (up to 30 days per member in and out of network combined)
  • Outpatient- 50% after deductible (24 visits per calendar year for physical therapy, occupational therapy, and/or chiropractic therapy; in and out of network combined)
    		•
    Skilled Nursing 70% after deductible (limited to 100 days per member per year in and out of network combined) 50% after deductible (limited to 100 days per member per year in and out of network combined)
    Home Health Care 70% after deductible (limited to 60 visits per member per year in and out of network combined) 50% after deductible (limited to 60 visits per member per year in and out of network combined)
    Mental Health
  • Biologically-Based Mental Illness Care- Coverage is no less extensive than the coverage provided for any other physical illness.
  • Other Mental Health Care:
    • Inpatient care- 70% after deductible
    • Outpatient care- 70% after deductible (up to a maximum of 40 days, in and out of network combined, per calendar year)
    		•
  • Biologically-Based Mental Illness Care- Coverage is no less extensive than the coverage provided for any other physical illness.
  • Other Mental Health Care:
    • Inpatient care- 50% after deductible
    • Outpatient care- 50% after deductible (up to a maximum of 40 days, in and out of network combined, per calendar year)
    		•
    Hospital Care 70% after deductible 50% after deductible
    Optional Benefits SmartSense Generic Only Rx 2500 SmartSense Generic Only Rx 2500