Plan Summary - AnyHealthInsurance.com

SmartSense 2500 (Standard Drug Coverage)

Amounts shown for covered services are your share of costs In-Network Benefits
	SmartSense 2500 (Standard Drug Coverage)
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Insurance Company
Plan Type - PPO \| HMO \| HSA	PPO
Annual Deductible	$2,500 individual; $5,000 family
Annual Out-Of-Pocket (includes Annual Deductible)	$5,000 individual; $10,000 family
Doctor Visit	First 3 visits: $30 copay (deductible waived); additional visits: 30% coinsurance after deductible
Lifetime Maximum	$7,000,000
Inpatient	30% coinsurance after deductible
Outpatient	30% coinsurance after deductible
Maternity	Not covered
Emergency Services	$100 copay(waived if admitted) + 30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
X-Ray & Lab	30% coinsurance after deductible
Annual Check up	30% coinsurance (deductible waived) OR $25 or $75 copay for basic or premium screening at HealthyCheckSM Centers (deductible waived)
Pap Smear/Mammogram	30% coinsurance after deductible
Physical Therapy	30% coinsurance after deductible, plan pays up to $2,500 per year
Acupuncture	Not covered
Chiropractic Care	30% coinsurance after deductible, plan pays up to $500 per year
Generic Rx	$15 copay (Tier 1)
Brand Name Rx	Formulary Brand name drugs (Tier 2): $40 copay; Non-Formulary Brand name drugs (Tier 3): $60 copay (after $7,500 Brand name deductible)
Term Life Coverage	Optional
Dental	Optional
Vision	Not covered
Eligibility	Reside in California at least 3 months
Available Effective Date	Any Day
Plan Limitations And Restrictions	PDF
Insurance Company
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	SmartSense 2500 (Standard Drug Coverage)