Page 5 - 2018 USI Enrollment
P. 5
University of Southern Indiana
2018 Medical Benefits Anthem Provider
This plan summary is intended to be a brief outline of your in-network Search
coverage. The entire provisions and out-of-network beneits are contained To get the highest level of
in the group contract. Co-insurance percent relects the employee share. coverage from your plan, use
In-Network participating healthcare
providers. Receiving services from
Core Plan HSA Plan
Annual Deductible Embedded a participating In-Network provider
reduces your out-of-pocket healthcare
Single $750 $2,700 costs. To conirm if your provider
Family $1,500 $5,400 is participating or to search for
Out-of-Pocket Limit (Includes Deductible) providers, just follow these simple
Single $4,500 $5,000 steps.
Family $9,000 $10,000 1. Go to www.anthem.com and
Lifetime Maximum Unlimited click menu and then select Find A
Hospital Doctor
Inpatient 20% after deductible 20% after deductible
Outpatient 20% after deductible 20% after deductible 2. Enter your username/password or
continue as a guest
Emergency Room $250 copay 20% after deductible
Physician Visits and Ancillary Services 3. If you continue as guest, enter in
Preventive Care 0% 0% the required ields and continue
Live Health Online $15 copay 20% after deductible
Primary Care (family or general $30 copay 20% after deductible Mail Order Delivery
practitioner, internal medicine,
pediatrician, OB/GYN) You could save money by ordering
Specialist Visits $30 copay 20% after deductible up to a 90-day supply of medication.
Chiropractic Care $30 copay 20% after deductible Make fewer trips to the pharmacy and
Urgent Care $75 copay 20% after deductible avoid waiting in line. Your medication
is shipped directly to your home.
Lab Services 20% after deductible 20% after deductible
X-Ray/Radiology 20% after deductible 20% after deductible
Prescription Drugs
Retail (30-day supply)
Tier 1 $10 20% after deductible
Tier 2 $40 20% after deductible
Tier 3 $60 20% after deductible
Tier 4—Specialty* $150 20% after deductible
Mail Order (90-day supply)
Tier 1 $20 20% after deductible
Tier 2 $80 20% after deductible
Tier 3 $120 20% after deductible
* Specialty medications must be obtained via Anthem’s Specialty Pharmacy Home Delivery
network in order to receive network level beneits.
5
2018 Medical Benefits Anthem Provider
This plan summary is intended to be a brief outline of your in-network Search
coverage. The entire provisions and out-of-network beneits are contained To get the highest level of
in the group contract. Co-insurance percent relects the employee share. coverage from your plan, use
In-Network participating healthcare
providers. Receiving services from
Core Plan HSA Plan
Annual Deductible Embedded a participating In-Network provider
reduces your out-of-pocket healthcare
Single $750 $2,700 costs. To conirm if your provider
Family $1,500 $5,400 is participating or to search for
Out-of-Pocket Limit (Includes Deductible) providers, just follow these simple
Single $4,500 $5,000 steps.
Family $9,000 $10,000 1. Go to www.anthem.com and
Lifetime Maximum Unlimited click menu and then select Find A
Hospital Doctor
Inpatient 20% after deductible 20% after deductible
Outpatient 20% after deductible 20% after deductible 2. Enter your username/password or
continue as a guest
Emergency Room $250 copay 20% after deductible
Physician Visits and Ancillary Services 3. If you continue as guest, enter in
Preventive Care 0% 0% the required ields and continue
Live Health Online $15 copay 20% after deductible
Primary Care (family or general $30 copay 20% after deductible Mail Order Delivery
practitioner, internal medicine,
pediatrician, OB/GYN) You could save money by ordering
Specialist Visits $30 copay 20% after deductible up to a 90-day supply of medication.
Chiropractic Care $30 copay 20% after deductible Make fewer trips to the pharmacy and
Urgent Care $75 copay 20% after deductible avoid waiting in line. Your medication
is shipped directly to your home.
Lab Services 20% after deductible 20% after deductible
X-Ray/Radiology 20% after deductible 20% after deductible
Prescription Drugs
Retail (30-day supply)
Tier 1 $10 20% after deductible
Tier 2 $40 20% after deductible
Tier 3 $60 20% after deductible
Tier 4—Specialty* $150 20% after deductible
Mail Order (90-day supply)
Tier 1 $20 20% after deductible
Tier 2 $80 20% after deductible
Tier 3 $120 20% after deductible
* Specialty medications must be obtained via Anthem’s Specialty Pharmacy Home Delivery
network in order to receive network level beneits.
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