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Get
a SmartSense
Quote
and/or Apply Online
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Anthem
SmartSense
Plan Details:
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Plan Benefits
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In-Network
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Out-of-Network
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Annual Deductible Choices
(separate for In-Network and
Out-of-Network)
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Individual
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$500 / $1,500 / $2,500 / $5,000 / $7,500
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$5,000 / $5,000 / $5,000/ $5,000 / $7,500
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Family
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$1,000 / $3,000 / $5,000 / $10,000 /$15,000
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$10,000 / $10,000 / $10,000 /$10,000 /$15,000
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Each family member has an individual deductible.
The family deductible can be satisfied by 2 or more
members.
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Annual
Out-of-Pocket
Maximum1
(includes deductible)
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Individual Maximum
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$3,000/$4,000/$5,000/$7,500/$10,000
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$15,000/$15,000/$15,000/$15,000/$17,500
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Family Maximum
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$6,000/$8,000/$10,000/$15,000/$20,000
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$30,000/$30,000/$30,000/$30,000/$35,000
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Each family member has an individual out-of-pocket
maximum. The family out-of-pocket maximum can be
satisfied by 2 or more members.
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Lifetime Maximum
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Paln pays up to $7 Million per member
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Covered Services
The amounts shown are your share of
costs after any deductible
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In-Network
Coinsurance amounts are
percentage of negotiated fee
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Out-of-Network
Coinsurance amounts are
percentage of negotiated fee, plus any amounts charged
over that fee
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Doctors’ Office Visits
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$30 copay for first 3 visits
per member per year
(deductible waived);
after 3 visits and once deductible is met, then 30%
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50%
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Professional Services
(x-ray, lab, anesthesia, surgeon, etc.)
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30%
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50%
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Hospital Inpatient
(overnight hospital stays)
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30%
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50%
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Hospital Outpatient
(if you don’t stay overnight)
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30%
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50%
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Emergency Room Services
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30%
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30%
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Maternity
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not covered
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Preventive Care
(Including appropriate screening for breast,
cervical, ovarian, and prostate cancer)
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Routine mammogram, Pap and PSA tests:
30%
Children's Services:
30%
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50%
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Physical Therapy, Occupational Therapy and
Chiropractic Services
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30%
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50%
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Plan covers up to a total of 24 visits per year.
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Prescription Drug Coverage
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In-Network
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Out-of-Network
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Comprehensive
Prescription Drug Coverage
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Generic: $15 copay
(or 40%, whichever is greater)
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not covered
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Brand-name/Specialty
$500 annual deductible applies before the following:
Brand-name: $15 copay
(or 40%, whichever is greater, not
to exceed $500 per prescription)
Specialty: 40%
$5,000 annual out-of-pocket maximum
(the most you'll have to pay)
In-network only and in addition to
brand-name/specialty deductible
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Generic Prescription Drug Coverage
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Generic Coverage ONLY
$15 copay (or 40%, whichever is greater)
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