Medical Plans Overview
Similarities and Differences between Medical Plans
Preventive care services for all plans
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 coinsurance applies. Preventive care services may include:
- Routine and periodic wellness exams.
- Routine immunizations for adults and children.
- Screening tests such as mammograms, bone density testing, PSA and cholesterol labs.
- Women’s health services including oral contraceptives, IUDs, hormone implants, injections, and sterilization.
- Pediatric fluoride, iron, folic acid, low dose aspirin, and tobacco cessation products up to certain limits. Over the counter medications require a prescription.
See list of Preventive Medical Services for all plans (PDF)
You may call Anthem or IU Health customer service using the number on your ID card for additional information about these services or view the federal government’s websites:
Similarities between the Medical plans
- There are no pre-existing condition limits or waiting periods. After enrolling, coverage is effective from the first day of eligibility.
- Services are comprehensive and include those that are traditionally covered by medical insurance: medical, prescription, behavioral health, transplants, durable medical equipment, home health care, skilled nursing, physical, occupational, and speech therapies, chiropractic services, and vision wear.
- Each plan’s out-of-pocket expenses vary, but the types of services covered under the plans are the same.
- Preventive services are covered at 100% when in-network providers are used.
- Each plan offers a Vision Wear Benefit.
- Each plan has annual out-of-pocket maximums for individual and family levels. Once the maximum is met, the plan pays 100% for in-network covered services for the remainder of the year.
- There is no lifetime maximum benefit on medical services.
Differences between the Medical Plans
- Out-of-pocket expenses (deductible levels, copays, and coinsurance)
- Provider networks. The PPO plans have a nationwide network and provide out-of-network benefits. The IU Health HDHP is an exclusive network with limited or no out-of-network benefits.
- Residency requirements e.g., IU Health HDHP is only available in certain counties
- How the deductible is structured in an HDHP plan versus a traditional plan (i.e., $500 Deductible plans)
- How the prescription benefit is structured in an HDHP plan versus a traditional plan
- A unique tax-advantaged health savings account (HSA) plan available to participants enrolled in either the Anthem PPO HDHP plan or the IU Health HDHP
Overview of the HDHP Plans and Traditional Deductible Plans
High Deductible Health Plans (HDHP)
IU offers two HDHP medical plans that meet the IRS requirements for allowing eligible employees and the university to make tax-free contributions to an employee-owned Health Savings Account (HSA). An HSA can be used tax-free free to pay for medical expenses, like deductibles and coinsurance, or saved to use in the future, even in retirement.
Both HDHP plans include comprehensive medical coverage; however, provider networks, the member’s share of medical costs (deductibles and coinsurance), premiums, and the university’s contribution to the employee’s HSA differ between the plans.
In an HDHP plan the deductible and out-of-pocket maximums are applied differently than a traditional PPO plan (e.g., the $500 Deductible plan), and there are IRS eligibility restrictions when enrolling in the HSA plan, so reading the plan details is important.
See Preventive Drug List for HDHP plans (PDF)
IU Health HDHP (more information)
The IU Health HDHP exclusively uses the IU Health provider network and its affiliates. The availability of the IU Health network hospitals and providers are more robust in certain counties around the state than in others see the plan summary for specifics.
There are no out-of-network benefits except in the case of an emergency, urgent care when more than 50 miles from home, or for a dependent of an Indiana-resident employee when the dependent lives outside the state of Indiana for reasons other than medical treatment.
The plan deductible ($2,500 employee-only / $5,000 all other coverage levels) applies to all covered services and prescriptions except preventive medical services and preventive prescriptions. Preventive medical services are covered at 100% when IUH network providers are used. Some preventive prescriptions, as outlined in the Affordable Care Act (ACA), are covered at 100% by the plan (no deductible or coinsurance applies). While other preventive prescriptions bypass the deductible and are only charged at the coinsurance (20%) rate.
After the deductible is met, a 20% coinsurance applies to all covered services and prescriptions until an out-of-pocket maximum ($3,000 employee-only / $6,000 all other coverage levels) is met. Both the deductible and coinsurance count toward the out-of-pocket maximum.
The university contribution to an employee’s HSA only partially covers the deductible--$1,600 employee-only / $3,200 all other coverage levels. The member is responsible for the difference between the IU contribution and the deductible ($900 difference for employee-only / $1,800 for all other coverage levels).
Anthem PPO HDHP (more information)
This plan has a nationwide network of providers. There are out-of-network benefits, however; the member pays less when network providers are used. The in-network deductible ($1,350 employee-only / $2,700 all other coverage levels) applies to all covered services and prescriptions except preventive medical services and preventive prescriptions.
Preventive medical services are covered at 100% when In-Network providers are used. Some preventive prescriptions as outlined in the Affordable Care Act (ACA), are covered at 100% by the plan (no deductible or coinsurance applies). While other preventive prescriptions bypass the deductible and are only charged at the coinsurance (20%) rate.
After the deductible is met, a 20% coinsurance applies to all covered services and prescriptions until an out-of-pocket maximum ($2,700 employee-only / $5,400 all other coverage levels) is met. Both the deductible and coinsurance count toward the out-of-pocket maximum.
The university contribution to an employee’s HSA is: $1,300 employee-only/$2,600 all other coverage levels.
Traditional Deductible Plan
Anthem PPO $500 Deductible Plan (more information)
IU pays 80% of in-network medical costs once the plan deductible is reached. Preventive medical services are covered at 100% when In-Network providers are used. There is an out-of-pocket maximum after which services are covered at 100% for the remainder of the plan year.
Retail and mail order prescription copays are based on a tiered drug list. In general, Tier 1 is generic drugs, Tier 2 is preferred brand drugs, and Tier 3 includes non-preferred drugs. There is a separate out-of-pocket maximum from the medical plan on in-network prescription copays.