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2018 Anthem PPO $500 Deductible FAQ and Resources

Frequently Asked Questions (FAQ)

The following questions and answers will help you better understand the Anthem PPO $500 Deductible Health Plan.

Comprehensive Coverage

Are the types of services covered under this plan different than other IU medical plans?

No. The plan covers medical, prescription, behavioral health, and transplant services the same as other IU employee medical plans.  The difference is primarily in the deductibles and copays.

Are pre-existing conditions covered?

Yes.  IU-sponsored employee medical plans do not have any pre-existing condition limits on new enrollees or when an employee moves from one IU plan to another.

Is there any waiting period before certain services are covered?

No.

Deductibles and Out-of-Pocket Maximums

What are the deductibles and out-of-pocket maximums for 2018?

  • 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).
  • 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.

How does the deductible work in this plan? 

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.

Once the individual deductible has been met for the plan year for a participant, that particular participant moves into the coinsurance 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 coinsurance phase. Mom then meets her $500 deductible in expenses and moves into the coinsurance 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 coinsurance phase.

After I have met the deductible, what is the coinsurance in this plan?

Once the deductible is met, there is a 20% in-network coinsurance on most services including medical and behavioral health services. The out-of-network coinsurance is generally 40%.

How does the medical out-of-pocket maximum work?

No family member may contribute more than $2,400 toward the family out-of-pocket maximum. The medical deductible and coinsurance apply to this maximum. In-network and out-of-network deductibles, coinsurance 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.

 
How does the prescription out-of-pocket maximum work?

There is an out-of-pocket maximum on the member’s cost for in-network prescriptions separate from the medical out-of-pocket maximum. Once prescription expenses reach the out-of-pocket maximum—$4,250 for employee-only coverage level or $6,100 when family members are covered—the plan will pay 100% of the in-network covered prescriptions for the remainder of the plan year. Medical expenses do not count toward the prescription out-of-pocket maximum.

What services does the deductible apply to?

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.

Network Services and Providers

Which physicians and hospitals can I use?

The plan uses Anthem Blue Access in Indiana and Blue Cross & Blue Shield (“Blue Card” providers) in other states and overseas. (This is the same medical provider network that the Anthem PPO $500 Deductible plan uses.) You can still receive benefits if you use out-of-network providers, but you will have higher out-of-pocket costs. See www.anthem.com or www.bluecares.com

Which pharmacies can I use?

Outpatient prescription drug benefits are through CVS Caremark. These are the same pharmacies that all the IU plans use; therefore, if you switch from another IU-sponsored medical plan to the Anthem PPO $500 Deductible Health Plan, you don’t have to change pharmacies. You can still receive benefits if you use out-of-network providers, but you will have higher out-of-pocket costs.  Most pharmacies are in-network, for example; CVS, Wal-Mart, Target, Kroger, K-Mart, Marsh, and Meijer.

Which behavioral health providers can I use?

You can use Anthem Behavioral Health providers, the same network the PPO plans use.  Go to www.anthem.com for a list of in-network providers.

Preventive Services

How are preventive services covered?

Preventive care services are covered at 100% (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. View a list of Preventive Medical Services (PDF) here.

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:

Vision Wear Benefit

Does my health care coverage include vision?

Yes. The Vision Wear benefit is provided through Anthem Blue View Vision and is included in your enrollment in the Anthem PPO $500 Deductible plan. Covered vision services have their own schedule of benefits and network providers separate from your medical benefits. Additionally, the medical plan deductibles and coinsurance do not apply to vision benefits, and the amount you pay for vision services does not accumulate toward the medical plan deductible or out-of-pocket maximums.

What does my vision coverage include?

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, coinsurance and out-of-pocket maximums apply to medical eye services.

Benefits include:

  • 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 Wear Benefit page for more information.

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