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What Individual health care plans do not cover

admin — Sat, 18 Apr 2009 05:04:14 +0000

The following are Exclusions and Limitations that will help you understand what a health care plan does not include before you enroll. These listings are an overview only. For a comprehensive list of the plans’ exclusions and limitations, you can should request a copy of a Policy/Combined Evidence of Coverage and Disclosure Form (EOC) booklet.

Exclusions and Limitations

Conditions covered by workers’ compensation or similar law.
Experimental or investigative services.
Services provided by a local, state, federal or foreign government, unless you have to pay for them.
Services or supplies not specifically listed as covered under the Policy/EOC.
Services received before your effective date or after coverage ends.
Any services received by Medicare benefits without payment of additional premium.
Services or supplies that are not medically necessary.
Routine physical exams, except for preventive care services (e.g., physical exams for insurance, employment, licenses or school are not covered), except as specifically stated in the Policy/EOC.
Any amounts in excess of the maximum amounts listed in the Policy/EOC.
Sex changes.
Cosmetic surgery.
Services primarily for weight reduction except medically necessary treatment of morbid obesity.
Dental care, dental implants or treatment to the teeth, except as specifically stated in the Policy/EOC.
Hearing aids.
Contraceptive drugs and/or certain contraceptive devices, except as specifically stated in the Policy/EOC.
Infertility services.
Private duty nursing.
Eyeglasses or contact lenses, except as specifically stated in the Policy/EOC.
Vision care including certain eye surgeries to replace glasses, except as specifically stated in the Policy/EOC.
Mental and nervous disorders and substance abuse, except as specifically stated in the Policy/EOC.
Certain orthopedic shoes or shoe inserts, except as specifically stated in the Policy/EOC.
Services or supplies related to a preexisting condition.
Telephone or facsimile machine consultations.
Outdoor treatment programs.
Educational services except as specifically provided or arranged by Anthem Blue Cross.
Nutritional counseling or food or dietary supplements, except for formulas and special food products to prevent complications of phenylketonuria (PKU).
Care or treatment furnished in a non-contracting hospital, except as specifically stated in the Policy/EOC.
Personal comfort items.
Custodial care.
Certain genetic testing.
Outpatient speech therapy, except as specifically stated in the Policy/EOC.
Any amounts in excess of maximums stated in the Policy/EOC.
Outpatient drugs, medications or other substances dispensed or administered in any outpatient setting.
Services or supplies provided to any person not covered under the Agreement in connection with a surrogate pregnancy.

Vital Shield Plus for Blue Shield of California

admin — Thu, 29 Jan 2009 02:19:36 +0000

Vital Shield^SM Plus* offers valuable California health insurance coverage for individuals and families, as a low-cost option for those who rarely go to the doctor, but want to know they’re covered when they do. Built on the success of the Vital Shield* plans, the Vital Shield Plus plans offer all the same great benefits plus a whole lot more.

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With Vital Shield Plus, members get¹

Lower annual out-of-pocket maximum and a lower annual deductible than with Vital Shield plans

Members can have the confidence they’re protected in case of unexpected medical problems or emergencies, without copayments after the out-of-pocket maximum is met, for most covered services
Annual out-of-pocket maximums as low as $2,900
Annual medical Deductibles as low as $400

Generic-only or coverage with brand-name prescription drugs

Vital Shield Plus plans give your customers prescription drug coverage options:
- Generic prescription drug only plan ($10 copayment)
- Generic/brand-name prescription drug combination plan ($10 copayment for generic prescription drugs/$45 copayment for brand-name prescription drugs, after an annual $500 brand-name deductible)
Prescription drug coverage is not subject to medical deductible

Fourth quarter deductible carry-over

The fourth quarter deductible carry-over allows members who do not meet their annual deductible to apply covered expenses from October to December toward the next year’s deductible
Vital Shield Plus plans also offer a range of annual deductible options to fit your customers’ specific needs

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Five physician office visits before the annual deductible and a lower copayment than Vital Shield plans

Five physician office visits are covered for a $30 copayment per visit prior to meeting the annual deductible

Family coverage with lower rates than Vital Shield plans

Vital Shield Plus plans offer both individual and family coverage

Ideal for individuals and families

Individuals who only expect to go to the doctor a few times a year
Individuals who are not planning to have children or additional children in the near future
Younger adults may want to consider lower deductibles ($400 for “young invincibles”, $900 for couples)
Older adults may want to consider higher deductibles ($2,900 for established families and empty nesters)

Tips for families

Families can save money with Vital Shield Plus by enrolling as a family instead of enrolling individually
If there are three or more family members, total family deductibles and out-of-pocket maximums would be lower per person on a family plan than with individual plans
Benefits are per member, so each family member gets the same number of office visits

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Vital Shield Plus Plan Benefits²

Available for individuals and families

Office visits and preventive exams

First 5: $30 (deductible n/a), then $0 after out-of-pocket maximum

Brand Rx

$45 after $500 brand Rx deductible (optional)

Generic Rx

$10 (deductible n/a)

Gynecological

40% (deductible n/a) + preventive exam copayment

Lab and X-ray

$0 after out-of-pocket maximum

Emergency room

$100 + 40% after deductible

Ambulance

40% after deductible

Hospitalization

40% after deductible

Maternity

Not covered

Deductible and out-of-pocket maximum options

Plan

400

900

2900

Deductible

$400 / $800 (family)

$900 / $1,800 (family)

$2,900 / $5,800 (family)

Out-of-pocket maximum

$2,900 / $5,800 (family)

$3,900 / $7,800 (family)

$4,900 / $9,800 (family)

1 Please note that Vital Shield Plus plans do not include maternity benefits.
2 Amounts shown represent the member’s financial responsibility when using Blue Shield network provides.
* Vital Shield and Vital Shield Plus plans are underwritten by Blue Shield of California Life and Health Insurance Company and are pending regulatory approval.

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Anthem Blue Cross RightPlan 40

admin — Mon, 08 Dec 2008 03:14:26 +0000

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A simple plan design with no medical deductible.

Looking for a California health insurance plan that’s easy to use but still has the benefits you need? Our RightPlan PPO 40 offers:

No medical deductible to worry about. Benefits are immediate – with a $40 copay for doctor visits.

Lower rates on services when you use our PPO network of more than 50,000 doctors and 400 hospitals.

Choice of three prescription drug coverage options. With no deductible on generic drugs.

Single policy coverage. This means that each family member gets his or her own policy.

Health and wellness programs. Learn how to improve your health with online access to health-related information, tools and product discounts.

Out-of-state coverage. This protects you from the high cost of unexpected emergencies when you travel.

For extra security, Anthem Blue Cross offers dental and life insurance plans that you can add to your medical coverage.

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Get Prices for the RightPlan PPO 40

Benefits-at-a-glance for RightPlan PPO 40


Plan Benefits		RightPlan PPO 40
		In-Network	Out-of-Network
Annual Deductible Choices	Individual	$0
	Family
Annual Out-of-Pocket Limit¹ (in addition to deductible, if any)	Individual	$7,500
	Family	Not applicable
Lifetime Maximum		Plan pays up to $5 Million per member

Covered Services The amounts shown are your share of costs after any deductible		In-Network	Out-of-Network
Doctors’ Office Visits		$40 copay	50% of negotiated fee plus all excess charges
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)		40% of negotiated fee	50% of negotiated fee plus all excess charges
Hospital Inpatient (overnight hospital stays)		40% of negotiated fee²plus $500 copay per day for first four days, per admission	All charges except $650 per day
Hospital Outpatient (if you don’t stay overnight)		40% of negotiated fee²plus $500 copay per surgical admission	All charges except $380 per day
Emergency Room Services ($100 copay applies for each visit; waived if admitted as inpatient)		40% of negotiated fee	40% of customary and reasonable fees plus all excess charges
Maternity		not covered
Preventive Care (tests ordered by physician are covered, including appropriate screening for breast, cervical, ovarian, and prostate cancer)	Adult Services	HealthyCheck Centers: $25/$75 copay for basic/premium screening Routine mammogram, Pap and PSA tests: $40 office visit plus 40% of negotiated fee	50% of negotiated fee plus all excess charges
	Children’s Services	Well-Child (through age 6) $40 office visit plus 40% of negotiated fee
Acupuncture / Acupressure		All charges except $25 per visit, up to 24 visits per year
Chiropractic Services		40% of negotiated fee	All charges except $25 per visit
		Plan covers up to 12 visits per year

Prescription Drug Coverage Options		In-Network	Out-of-Network
Comprehensive Prescription Drug Coverage		Generic: $10 copay Brand-name: $30 copay after $500 brand-name deductible	50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits; subject to the $500 annual brand-name prescription drug deductible
Generic Prescription Drug Coverage		$10 copay	50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits.
No Prescription Drug Coverage		This option is available with RightPlan PPO 40

1. Excludes non-participating charges in excess of the Anthem Blue Cross negotiated fee and non-participating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and non-participating providers apply to annual calendar year out-of-pocket limit except where specifically noted in the policy.
2. Additional $500 admission charge at participating hospitals (no additional charge for preferred participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for ambulatory surgical centers or medical emergencies.

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Anthem Blue Cross of California Individual HMO Plan

admin — Wed, 05 Nov 2008 16:45:38 +0000

No medical deductible with full network access

For the most complete HMO coverage, Individual HMO offers you:

No medical deductible. Benefits are immediate with easy copays for doctor visits.

Access to our entire HMO provider network with nearly 300,000 doctors and 400 hospitals across California.

Maternity benefits. Important for growing families.

Brand-name and generic prescription drug coverage with an affordable $10 copay on generic drugs.

Emergency coverage that travels with you. If you travel out of state, you can rest assured that you’ll be covered in case of an emergency.

Get a quote and apply now!

Benefits-at-a-glance for the Individual HMO plan


Plan Benefits			Select HMO	HMO Saver	Individual HMO
Plan Benefits			In-Select Network¹	In-Network	In-Network
Annual Deductible			$0	$1,500 per member Inpatient / Outpatient Hospital Services and Ambulatory Surgical Centers	$0
Annual Out-Of-Pocket Limit (in addition to deductible, if any)	Individual		$3,000 per member	$1,500 per member	$3,000 per member
	Family		Once 2 members each reach the limit, the maximum is satisfied for the entire family	Once 2 members each reach the limit, the maximum is satisfied for the entire family	Once 2 members each reach the limit, the maximum is satisfied for the entire family
Lifetime Maximum (the plan will pay up to this amount)			unlimited	unlimited	unlimited

Covered Services The amounts shown are your share of costs after any deductible			In-Select Network¹	In-Network	In-Network
Doctors’ Office Visits			$25 copay	$10 copay per visit	$10 copay per visit
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)			No charge for office visit-related services	No charge for office visit-related services	No charge for office visit-related services
Hospital Inpatient (overnight hospital stays)			$250 copay per day up to the first four days, then 0% of negotiated fee per admission	20% of negotiated fee (after deductible)	20% of negotiated fee
Hospital Outpatient (if you don’t stay overnight)			20% of negotiated fee for services; $250 per surgery	20% of negotiated fee (after deductible)	20% of negotiated fee
Emergency Room Services ($100 copay applies for each visit; waived if admitted as inpatient)			20% of negotiated fee	20% of negotiated fee (after deductible)	20% of negotiated fee
Maternity			Office Visits: $25 copay Hospital Inpatient: $250 copay per day up to the first four days, then 0% of negotiated fee per admission Outpatient Services: 20% of negotiated fee	Office visits: $10 copay Inpatient/Outpatient: 20% of negotiated fee (after deductible)	Office visits: $10 copay Inpatient/Outpatient: 20% of negotiated fee
Preventive Care			$25 copay for specific health maintenance services	$10 copay for specific health maintenance services	$10 copay for specific health maintenance services
Ambulance			$50 copay (waived if admitted to hospital)	$50 copay (waived if admitted to hospital)	$50 copay (waived if admitted to hospital)
Chiropractic Services (up to 60 consecutive days following an illness or injury; provided with medical group referral only)		Inpatient	$0	20% of negotiated fee	20% of negotiated fee
		Outpatient	$25 copay per visit	$10 copay per visit	$10 copay per visit
Prescription Drug Benefits			Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible²(2 member maximum)	Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible²(2 member maximum)	Generic: $10 copay Brand-name: $30 copay after $250 Brand-name prescription drug deductible²(2 member maximum)