Using Your Medical Plan — Value PPO
Anthem Value PPO
(Administered by Anthem and Express Scripts)
The Anthem Value PPO features medical coverage administered by Anthem and prescription drug coverage administered by Express Scripts. The Value PPO has lower premiums, covers the same wide range of healthcare services and uses the same network of providers, but it has a higher annual deductible—per IRS rules—to be able to take advantage of a savings account feature.
With this plan, you decide whether to see a network-participating provider or go outside the network each time you need medical care. You do not need to choose a primary care physician (PCP) to coordinate your care. This plan has both in- and out-of-network deductibles, which apply to eligible medical and prescription drug expenses. (Eligible in-network preventive care, including well-woman care, is covered at 100% and not subject to the deductible.)
After you satisfy the in-network deductible, eligible medical expenses are covered at 100% or 80%, depending on the service. After you satisfy the out-of-network deductible, eligible expenses are generally covered at 50% (for exceptions, visit benefits.amgen.com and view the Summary Plan Description). You pay set copays for your prescription drugs, though you may need to meet the medical plan deductible first depending on your choice of medical plan. To provide financial protection, the plan has in- and out-of-network calendar-year out-of-pocket maximums based on your annual base pay. If you reach an out-of-pocket maximum, eligible expenses are covered at 100% for the remainder of that year.
* Note: Most people do not reach their out-of-pocket maximum(s) in any given year.
| Deductibles* | ||
|---|---|---|
| Coverage | In-Network | Out-of-Network |
| Staff member only | $1,500 | $3,000 |
| Family | $3,000 | $6,000 |
| Are prescription drugs included in the deductible? | Yes | Yes |
| Medical and Prescription Drug Out-of-Pocket Maximums | ||
| Annual Base Pay | In-Network | Out-of-Network |
| Less than $100,000 | $3,000/staff member only $6,000/family |
$7,500/staff member only $15,000/family |
| $100,000 – $199,999 | $4,000/staff member only $6,850/family |
$10,000/staff member only $20,000/family |
| $200,000+ | $5,000/staff member only $6,850/family |
$12,500/staff member only $25,000/family |
| Medical Coinsurance | ||
| Most covered services | 80% | 50% of R&C** after deductible |
| Preventive | 100% deductible waived | 50% of R&C after deductible |
| Primary Care (including OB/GYN visit*** or LiveHealth Online) |
100% after deductible | 50% of R&C after deductible |
| Specialist visit | 80% after deductible | 50% of R&C after deductible |
| Inpatient hospital stay | 80% after deductible | 50% of R&C after deductible |
| Outpatient surgery | 80% after deductible | 50% of R&C after deductible |
| Emergency room visit | 80% after deductible | 50% of R&C after deductible |
| Prescription Drug Copays | ||
| Preventive | 100% deductible waived | 100% deductible waived |
| Amgen products**** | 100% after deductible | 100% after deductible |
| Retail (up to 30-day supply) |
You pay $10 (generic); $30 (preferred/brand formulary); $50 (brand non-formulary) after deductible | 50% covered, after deductible |
| Mail-order (up to 90-day supply) |
You pay $25 (generic); $75 (preferred/brand formulary); $125 (brand non-formulary) after deductible | Not covered |
* In-network eligible expenses only apply toward your in-network deductible and in-network out-of-pocket maximum. There are some expenses that do not apply to your in-network deductible or in-network, out-of-pocket maximum. Out-of-network eligible expenses only apply toward your out-of-network deductible and out-of-network out-of-pocket maximum. For more information, visit MyHR and download the Summary Plan Description (SPD).
** Reasonable & Customary (R&C) charges refer to commonly charged or prevailing fees for healthcare services wit hin a geographic area. In addition to satisfying a higher deductible, paying a higher coinsurance rate, and being subject to higher out-of-pocket maximums, out-of-network benefits are based on usual and prevailing charges. For outpatient facility charges, out-of-network benefits are reduced to 50% of 150% of the Medicare Prevailing Rate.
*** Eligible in-network preventive care, including well-woman care, is covered at 100% before the deductible.
**** Electing an Anthem medical plan will ensure coverage for Amgen products. Amgen products are covered at 100% after deductible under the Value PPO.