2017 Anthem PPO $500 Deductible Medical Plan
For 2017, if you are enrolled in either the Anthem PPO HDHP or the Anthem PPO $500 Deductible plan you will receive a brand new Anthem medical card in the mail. The new cards have new group numbers and new member identification numbers.
In addition, your medical card will now also contain the information for your prescription coverage. This one card can be used at all of your medical, pharmacy, and vision providers.
You will need to use your new Anthem card at all of your providers starting January 1st. Please be sure to provide your new insurance card to each of your health providers as well as your pharmacy provider. Any claims submitted under the old insurance card will be denied.
The employee contribution to the medical plan premiums are deducted from the employee’s paycheck before taxes. The employee’s contribution rate is based on the employee’s annual base salary at the time payroll runs each month. For School of Medicine full-time faculty who receive a portion of their pay from an IU Health or VA paycheck, the annual base salary includes both the IU base salary and certain IU Health fixed and/or variable compensation, as determined by the School of Medicine.
Employee contributions to the premium costs can be reduced with the Tobacco-Free Premium Reduction Incentive. An employee can complete an affidavit indicating the employee and/or spouse does not use tobacco and will not in the future. Completing the affidavit will reduce the employee’s premium contribution by $25 per month for the employee or spouse, or $50 for both. For more information regarding this incentive, go to the Tobacco-Free Incentive page.
Employee’s Annual Base Salary*
|Employee & Child(ren)|
|Employee & Spouse|
Below is an example of how to calculate the employee’s monthly premium for an employee who:
- Enrolls in the Anthem PPO $500 Deductible plan
- With coverage level Employee w/Spouse
- Annual IU salary of $51,548
- Signed affidavit confirming employee and spouse do not use tobacco
$ 412.29 (employee contribution)
The Anthem PPO $500 Deductible plan includes comprehensive coverage for medical, prescription, behavioral health, and organ transplant services with no pre-existing condition limits or waiting periods. After enrolling, coverage is effective from the first day of eligibility. There is no lifetime maximum benefit on medical services.
- Anthem PPO $500 Deductible Benefit Summary
- Anthem PPO $500 Deductible Federal Summary of Benefits and Coverage
- Anthem PPO $500 Deductible Plan Booklet
Maximum Allowable Amount
This amount is also sometimes referred to as Covered Charges, Usual & Reasonable (U&R) charges, or Usual & Customary (U&C) charges. Benefits for Covered Services are based on the Maximum Allowable Amount, which is the maximum amount the Plan will pay for a given service. Network Providers accept the Maximum Allowable Amount as payment in full with no balance billing.
When a Non-Network Provider is used, the Member is responsible for any balance due between the Non-Network Provider’s charge and the Maximum Allowable Amount in addition to any Co-insurance, Deductibles, and/or non-covered charges. Co-insurance/Maximums are calculated based upon the Maximum Allowable Amount, not the Provider’s charge.
Deductible means the specified dollar amount of covered charges that must be paid by the Member before Anthem will begin to pay benefits for the remainder of the calendar year.
Unless otherwise stated in the Schedule of Benefits in the Plan Booklet, all health care benefits are subject to an in-network or separate out-of-network deductible. Each enrollee may contribute no more than the amount of the individual deductible to the family maximum. Each enrollee’s coverage begins after their individual deductible is met. The deductible applies to all covered services except emergency room and in-network urgent care centers, preventive care, prescription drugs (except drugs administered in a Physician’s office), and transplants.
- The in-network deductible is $500 individual deductible (per member) and $1,500 family deductible (when 3 or more individuals are covered).
- The out-of-network deductible is $900 individual deductible (per member) and $2,700 family deductible (when 3 or more individuals are covered).
Once the individual deductible has been met for the plan year for a participant, that particular participant moves into the co-insurance phase where the plan then shares in the cost of covered services.
If there are 3 or more family members covered, the maximum deductibles added together would not exceed $1,500. However, each member cannot contribute more than the individual deductible amount toward the family deductible (i.e. $500). For example, Dad meets his $500 deductible in expenses and moves into the co-insurance phase. Mom then meets her $500 deductible in expenses and moves into the co-insurance phase. Then Child #1 has $200 in expenses and Child #2 has $300 in expenses and Child #3 has $0 in expenses. The entire family deductible ($1,500) has been met and all members of the family would now be in the co-insurance phase.
Co-Insurance is the member’s share of the cost of a covered service. For example, if the plan pays 80%, the member’s co-insurance is 20% up to the maximum allowable amount. However, when choosing a Non-Network provider, the member is responsible for any balance due after the plan payment.
- The in-network co-insurance is 20%.
- The out-of-network co-insurance is 40%.
No family member may contribute more than $2,400 toward the family out-of-pocket maximum. The medical deductible and co-insurance apply to this maximum. In-Network and Out-of-Network deductibles, co-insurance and out-of-pocket maximums accumulate separately. Charges that do not apply to the medical out-of-pocket maximum include non-network provider charges above the Maximum Allowable Amount, adjustments to Covered Charges for services that were not pre-certified, covered charges for prescription drugs, and Out-of-Network transplant services.
- The in-network out-of-pocket maximums are $2,400 per member or $7,200 per family.
- The out-of-network out-of-pocket maximums are $6,850 per member or $13,700 per family.
For questions regarding benefit coverage, claims, and provider networks:
- Anthem Member Services: 844-736-0920
- Precertification Authorization: 800-345-4348
- Behavioral Health: 844-736-0920
- Travel Coverage: 800-810-2583
Anthem PPO $500 Deductible Member Costs
(up to $500 per member or $1,500 per family)
(after deductible and up to $2,400 per member or $7,200 per family)
(after having paid the deductible and co-insurance)
Preventive medical care services are covered at no cost (1) when network providers are used and (2) when services are consistent with the U.S. Preventive Services Task Force guidelines and nationally recognized schedules. Preventive care is generally provided when there are no current symptoms or prior history of a diagnosed medical condition associated with the service.
- Preventive medical services are covered at 100% when In-Network providers are used —no deductible or co-insurance applies. Preventive services include physical exams, well-child visits, immunizations, lab tests (e.g., Pap, PSA, cholesterol), contraceptive services (e.g., IUD’s and sterilization), and other screening diagnostic services like mammograms and colonoscopies.
- You may call Anthem customer service using the number on your ID card for additional information about these services or view the federal government’s websites:
Mental health and Substance Abuse benefits are provided in accordance with Federal Mental Health Parity. Benefits are covered as any other illness through Anthem Behavioral Health. Prior authorization is required.
For additional questions about Mental Health / Chemical Dependency coverage, claims and provider network, contact Anthem Behavioral Health at 844-736-0920.
The vision wear benefit is provided through Anthem Blue View Vision.
The vision benefit is a “carve-out” benefit meaning that it is included in the member’s enrollment in the medical plan, but the covered vision services have their own schedule of benefits and network providers separate from medical benefits. Additionally, the medical plan deductibles and co-insurance do not apply to vision benefits, and the amount the member pays for vision services do not accumulate toward the medical plan deductible or out-of-pocket maximums.
The vision benefit is for routine eye care and corrective eye care only. For medical treatment of the eyes, visit a medical network eye care physician. Medical eye care includes services for such conditions as eye injuries, glaucoma, and retinal detachment. The medical deductible, co-insurance and out-of-pocket maximums apply to medical eye services.
- A routine eye exam every 12 months, with a $10 copay.
- Frames, lenses and contacts covered with specific allowances and copays for in-network providers, see the Vision Benefit Summary for more specifics:
Express Scripts, the Pharmacy Benefit Manager (PBM), manages the prescription drug benefit under contract with the State of Indiana and Indiana University. Express Scripts maintains the Preferred Drug list (also known as a Formulary), manages a network of retail pharmacies and operates Mail Service and Specialty Drug pharmacies. This benefit covers most prescription drugs, plus insulin and some over-the-counter (OTC) diabetes supplies and certain other OTC items considered preventive under the Health Care Reform Act. Certain medications are subject to limitations and may require prior authorization for continued use.
Express Scripts pharmacy network includes most retail chain pharmacies, such as CVS, Walmart, Target, and most supermarket and club pharmacy chains. To locate network pharmacies, check prescription coverage and costs visit the Express Scripts Web site at www.expressscripts.com/iu. Retail Pharmacy Prescription Drugs (up to 30-day supply)
Retail Pharmacy Prescription Drugs (up to 30-day supply)
- Tier 1 Prescription Drugs (Generics): $8 Co-Pay
- Tier 2 Prescription Drugs (Preferred Brands): $25 Co-Pay
- Tier 3 Prescription Drugs (Non-Preferred Brands): $45 Co-Pay
- Non-covered Drugs (with Network discounts): 100% member responsibility
- Specialty Drugs are not covered at Retail
Mail Service Pharmacy Prescription Drugs (up to 90-day supply) and Specialty Drugs
- Tier 1 Prescription Drugs (Generics): $20 Co-Pay
- Tier 2 Prescription Drugs (Preferred Brands: $62 Co-Pay
- Tier 3 Prescription Drugs (Non-Preferred Brands): $112 Co-Pay
- Non-covered Drugs (with Network discounts): 100% member responsibility
There is an out-of-pocket maximum on the member’s cost for in-network prescriptions. Once prescription expenses reach the out-of-pocket maximum - $4,200 for employee-only coverage level or $6,000 when family members are covered – the plan will pay 100% of the in-network covered prescriptions for the remainder of the plan year.
Prescription - Express Scripts
Member Services: 800-988-1794
Mail Order Services: 800-988-1794
Vision - Anthem Blue View Vision
Member Services: 866-723-0515
IU - IU Human Resources
Benefit Questions: 812-855-1286