Blue Cross of California, Affordable Individual and Family Health Care Plans

SmartSense - Affordable Health insurance Plans

Is Blue Cross SmartSense for you?
• Reliable, basic protection with some of our lowest monthly rates make these plans affordable
• Choose the annual deductible/monthly rate combination that works for you
• Immediate benefits for first three visits to a doctor
• Choice of prescription drug benefits (Comprehensive Rx or Generic Only Rx)
• No need for maternity benefits
• Health plan pays up to $7,000,000 per member in lifetime benefits

What else do you get?
• Access to over 50,000 California PPO network doctors and specialists and nearly
400 hospitals – so chances are your doctor is one of ours
• Money in your pocket – because we’ve negotiated lower fees with our network
doctors and hospitals, your share of costs is less (a lot less)
• Free health and wellness programs – designed to keep you as healthy as can be
• Out-of-state coverage – so you’ll feel better wherever you are
And be sure to check out our dental and life coverage on pages 5 and 6.

Blue Cross SmartSense - These amounts show your share of costs after deductibles, if any.

1 Once a member meets their single deductible, their deductible is satisfied. After one family member’s
single deductible is satisfied, the family maximum can be met by one or more family members.
2 Excludes non-participating charges in excess of the 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 out-of-pocket maximum except where specifically
noted in the policy.
3 Applies to first three preventive care visits and/or doctors’ office visits.
4 Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient.
5 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and
ovarian cancer.
6 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician
writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for the
generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug.
The amount paid does not apply to the member’s brand-name deductible.
7 Not to exceed $500 maximum (the most you would need to pay) per brand-name prescription.
8 Specialty drugs include injected, infused, oral and inhaled medications that generally need to be closely
monitored by your doctor.These drugs tend to be higher in cost and often require special handling
and ordering.
9 The annual brand-name/specialty drug deductible and annual brand-name/specialty drug out-of-pocket
maximum are separate from the annual medical deductible and annual medical out-of-pocket maximum.
They are not combined for in-network and out-of-network.

What the Blue Cross Smartsense Medical Plans Do Not Cover
Please take a few moments to review the exclusions and limitations. We want you to understand what your
coverage does not include before you enroll.
These listings are an overview only. The SmartSense Policy booklet contains a comprehensive list of the plans’
exclusions and limitations. For a sample copy of a Policy booklet, ask your agent or contact BC Life & Health
Insurance Company.
Exclusions and Limitations
Pregnancy or maternity care.
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.
Services received before your effective date.
Services received after coverage ends.
Services you wouldn’t have to pay for without insurance.
Services from relatives.
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.
Any amounts in excess of the maximum amounts listed
in the Policy.
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.
Hearing aids.
Contraceptive drugs and/or certain contraceptive
devices, except as specifically stated in the Policy.
Infertility services.
Private duty nursing.
Eyeglasses or contact lenses, except as specifically
stated in the Policy.
Vision care including certain eye surgeries to replace
glasses, except as specifically stated in the Policy.
Mental and nervous disorders and substance abuse,
except as specifically stated in the Policy.
Certain orthopedic shoes or shoe inserts, except as
specifically stated in the Policy.
Services or supplies related to a pre-existing condition.
Outdoor treatment programs.
Telephone or facsimile machine consultations.
Educational services except as specifically provided or
arranged by Blue Cross.
Nutritional counseling.
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.
Personal comfort items.
Custodial care.
Certain genetic testing.
Outpatient speech therapy, except as specifically stated
in the Policy.
Outpatient drugs, medications or other substances
dispensed or administered in any outpatient setting.
Services or supplies supplied to any person not
covered under the Policy in connection with a surrogate
pregnancy.
Acupuncture/Acupressure.

No-Obligation Review Period
After you enroll in a plan offered by Blue Cross of California or BC Life & Health Insurance Company, you will receive
a Policy/EOC booklet that explains the exact terms and conditions of coverage, including the plan’s exclusions and
limitations. You have 10 full days to examine your plan’s features. During that time, if you are not fully satisfied,
you may decline by returning your Policy/EOC booklet along with a letter notifying us that you wish to discontinue
coverage. Policy/EOC booklets are available for you to examine prior to enrolling. Ask your agent or Blue Cross.
Rights and Obligations
Incurred Medical Care Ratio
As required by law, we are advising you that Blue Cross of California and its affiliated companies’ incurred medical care
ratio for 2006 was 81.53 percent. This ratio was calculated after provider discounts were applied.

Enrollment Guidelines
To enroll, you must be:
• Age 64 3/4 or younger;
• A permanent legal resident of California;
• A U.S. resident for at least the last 3 months;
• The applicant’s spouse or domestic partner, age 64 3/4 or younger;
• The applicant’s children (under 19 years of age), or the children (under 19 years of age) of the applicant’s enrolling
spouse or qualified domestic partner;
• The applicant’s unmarried dependent children between the ages of 19 through 22 (“dependent” as defined by the
Internal Revenue Service).
Medical Underwriting Requirement
We believe that the cost of our plans should be consistent with a member’s expected health care needs and risk
factors. That’s why Blue Cross SmartSense offers various levels of coverage. To determine individual medical risk factors, all
applications are subject to medical underwriting. Depending on the results of the underwriting review, a number of
things may happen:
• You may be offered coverage at the standard rate, or
• You may be offered the plan you selected at a higher rate, or
• You may not qualify for the plan listed in this brochure, or
• You may be offered an alternate plan.
If you have a significant medical condition and do not qualify for the plan in this brochure or if you have discontinued group
coverage, please contact your Blue Cross representative for information regarding other Individual coverage options.

Waiting Periods
There is a specific six-month waiting period for coverage of any condition, disease or ailment for which medical advice
or treatment was recommended or received within six months preceding the effective date of coverage. If you apply
for coverage within 63 days of terminating your membership with another “creditable” health care plan, then you
can use your prior coverage for credit toward the six-month waiting period. Blue Cross SmartSense will credit the time you were
enrolled in the previous plan. Consult with your Blue Cross agent or representative if you have a question about the
underwriting process.

Blue Cross of California (BCC) and BC Life & Health Insurance Company (BCL&H) are
Independent Licensees of the Blue Cross Association (BCA). Dental Blue and the
Blue Cross name and symbol are registered service marks of the BCA. SmartSense,
Dental Blue PPO and Term Life are offered by BCL&H. Dental SelectHMO is offered by BCC.
bluecrossca.com
Rates and benefits effective 12/1/07

Apply for Blue Cross of California Affordable Smartsense plans today at www.californiahealthinsurancenow.com

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