Blue Cross of California SmartSense 1500 with Comprehensive RX California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
SmartSense 1500 with Comprehensive RX
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
No 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
30% after deductible 
Office Visit
 
Primary Doctor
$30 copay for first 3 visits per member per year (deductible waived); after 3 visits 30% coinsurance after deductible 
Specialist
$30 copay for first 3 visits per member per year (deductible waived); after 3 visits 30% coinsurance after deductible 
Periodic Health Exam
30% Coinsurance after deductible 
Periodic OB-GYN Exam
30% Coinsurance after deductible 
Well Baby Care
30% Coinsurance after deductible (through age 6) 
Chiropractic
30% Coinsurance after deductible (plan pays up to $500 per year) 
Mental Health
Not covered 
Prescription Drugs
 
Generic
$15 Copay (or 40% Coinsurance, whichever is greater) 
Brand
$15 Copay (or 40% Coinsurance, whichever is greater); 40% of negotiated fee for self-administered injectables, except insulin 
Non-Formulary
50% Coinsurance after deductible 
Separate Rx Deductible
Medical Plan Deductible Applies 
Mail Order
Available
Outpatient Lab/X-Ray
30% Coinsurance after deductible 
Emergency Room
30% Coinsurance after deductible (additional $100 copay for each visit, waived if admitted) 
Outpatient Surgery
30% Coinsurance after deductible 
Hospitalization
30% Coinsurance after deductible 
Maternity
 
Pre & Postnatal Office Visit
Not covered 
Labor & Delivery Hospital Stay
Not covered 
Additional Information
Will insurance company obtain and pay for medical records?
Yes
eSign
(electronic signature)
Yes
A.M. Best Rating
A
as of 11/06/2006
More Insurance Plan Details
More Details
Exclusions and Limitations
Exclusions and Limitations
Actions
Company
Blue Cross of California
Plan Name
SmartSense 1500 with Comprehensive RX
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