• Anthem Blue Cross and Blue Shield

Health Plan Definitions

Pacificare SignatureValue®
A Health Maintenance Organization (HMO) focuses on the quality of care provided to its members - with prevention and wellness as the key components of that care. Health services are accessed through contracted primary care physicians (PCPs) who know the member's medical history and individual needs; thus a partnership is formed between the member, the provider and the health plan. HMOs offer minimal paperwork and low, predictable out-of-pocket costs. Members pay a small, predetermined copayment each time they receive health care services.


PacifiCare SignaturePOS® (POS)
A Point of Service (POS) plan offers members greater flexibility and options. POS plans combine the savings of an HMO with the flexibility of a typical indemnity arrangement. If you are looking for affordability, use the in-network option of your benefit plan. If you prefer to see a doctor who is not participating in our network, choose the out-of-network option.


PacifiCare SignatureOptionsSM (PPO)
A Preferred Provider Option is a plan which offers an even wider selection of physicians to our members. These participating providers may be primary care doctors or specialists and PPO members are free to see any of them. PPO members may also visit non-contracted providers, but at a higher out-of-pocket cost. PacifiCare SignatureOptionsSM is available to employer groups of 51 or more employees.


PacifiCare SignatureIndependenceSM (Indemnity)
The PacifiCare SignatureIndependence Plan is a traditional indemnity plan. It gives you the independence to go to any doctor -- including a specialist -- without a referral.

You have the flexibility to see any provider licensed or certified to provide covered benefits.
You must meet an annual deductible.
You pay your plan's coinsurance cost for all covered services.


PacifiCare SignatureFreedomSM (SDHP)
The PacifiCare SignatureFreedom plan is a Self Directed Health Plan, or SDHP. It is PPO-based, so you'll have access to a broad network of physicians and hospitals. PacifiCare SignatureFreedom rewards you with an annual Self Directed Account (SDA) which you can use toward certain types of preventative health care services like doctor's office visits, mammography screening, breast and pelvic exams, and more.

You can choose any provider licensed or certified to provide covered benefits.
You pay a lower copayment or coinsurance when you visit a doctor that is in the participating network.
Any money from your SDA that you don't spend is carried over to the next year, allowing you to "save" for future health care expenses.
Services not covered by the SDA, such as inpatient surgery or emergency room visits, are paid for like a traditional PPO, with yearly deductible and a charge for coinsurance.
You have access to a complete suite of online support tools that allow you to keep track of your SDA account, claim activity, status, provider choice and health care costs.


Medicare Advantage
In addition to our regular HMO product, PacifiCare offers Medicare beneficiaries Secure Horizons an alternative to Medicare. Secure Horizons, our Medicare HMO plan, essentially works the same as our regular HMO. When a member chooses a PCP, he or she is also choosing the group of specialists available and the hospital they will go to when necessary. This plan covers all services and supplies offered by Medicare, plus additional benefits, often at little or no premium to the member

If the application is approved, with or without lifetime benefit exclusion(s), the effective date of enrollment will be listed on the subscriber's coverage notice. Memberships are effective on the date assigned by Anthem. If the entire application is not approved, Anthem will disclose, in writing, the reason(s) for non-acceptance and what needs to be done for reconsideration, if applicable.

If any member is approved with a lifetime benefit exclusion, the amendment will be included in the membership certificate or sent with the letter notifying the member of the lifetime benefit exclusion.

The following waiting period for pre-existing conditions applies to all members –

A pre-existing condition is an injury, sickness or pregnancy, for which the member has, during the 12 consecutive months immediately preceding the member’s original membership effective date, either (1) incurred charges, (2) received medical treatment, (3) consulted a health care professional, or (4) taken prescription drugs. We will not pay for services related to a pre-existing condition for 12 consecutive months after the member’s original membership effective date. I further understand that my coverage will not pay for services unless they are medically necessary as determined by Anthem.

Anthem must receive a 30-day advance notification to cancel your coverage. Anthem has 60 days to process your application.

No person other than the applicant shall alter any written application for any policy without the applicant’s written consent. The exception is that the insurer may make insertions, for administrative purposes only, in such manner as to indicate clearly that such insertions are not ascribed to the applicant.

In no event shall the Company incur any liability before an application is approved or with respect to an application that has been declined. No coverage shall exist under the agreement for which the application is made until approved by the Underwriting Department.