Anthem PPO
Preventive Care: The plan pays 100% for in-network preventive care.
Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $5,000 for Individual coverage and $10,000 for Family coverage when you use in-network providers.
Coinsurance: Once you have met the deductible, you will pay coinsurance for services received. When you use in-network providers, your coinsurance cost will be 20% for individual and family.
Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. The medical and prescription drug deductible, copayments and coinsurance all apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.
LiveHealth Online (LHO): This is Anthem’s telemedicine option. MDLive lets you get the care you need – including most prescriptions (when appropriate) – for a wide range of minor conditions. You can connect with a board certified provider via video chat or phone, when, where and how it works best for you. Download the LHO flyers in the Resource Box for additional information.
Health Reimbursement Arrangement (HRA): Singles are responsible for the first $500 and those covering dependents responsible for the first $1,000. Additional information can be found in the summary under resources.
Resources
| Covered Services | Network | Non-Network |
| Calendar Year Deductible: Single/Family | $5,000 / $10,000 | $15,000 / $30,000 |
| Coinsurance | 20% after deductible | 50% after deductible |
|
Maximum Out of Pocket Limit: Single / Family |
$7,500 / $15,000 | $22,500 / $45,000 |
| Office Visit | $35 copay | 50% after deductible |
| Specialist Office Visit | $70 copay | 50% after deductible |
| Urgent Care Centers | $75 copay | 50% after deductible |
| Emergency Medical Care | $400 copay + 20% | 50% after deductible |
| In-Patient Hospital Services | 20% after deductible | 50% after deductible |
| Out-Patient Hospital Services | 20% after deductible | 50% after deductible |
Prescription Drug Coverage: Essential Drug List Tier 4.
Click HERE to view the formulary or download under Resources.
| Prescription Drug Benefits | Preferred Network Provider | In-Network Provider | Non-Network Provider |
| Deductible | Not Applicable | Not Applicable | Not Applicable |
|
Tier 1: Generic Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. |
$10 copay per prescription (retail) and $20 copay per prescription (home delivery) | $20 copay per prescription (retail) and Not covered (home delivery) |
50% coinsurance (retail) and Not covered (home delivery) |
|
Tier 2: Preferred Brand Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. |
$40 copay per prescription (retail) and $100 copay per prescription (home delivery) |
$50 copay per prescription (retail) and Not covered (home delivery) | 50% coinsurance (retail) and Not covered (home delivery) |
|
Tier 3: Non-Preferred Brand Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. |
$70 copay per prescription (retail) and $175 copay per prescription (home delivery) |
$80 copay per prescription (retail) and Not covered (home delivery) | 50% coinsurance (retail) and Not covered (home delivery) |
|
Tier 4: Specialty Covers up to a 30 day supply (retail pharmacy). Covers up to a 30 day supply (home delivery program). |
25% coinsurance up to $350 per prescription (retail and home delivery) | 25% coinsurance up to $450 per prescription (retail) and Not covered (home delivery) | 50% coinsurance (retail) and Not covered (home delivery) |