PPO Medical Plans
The Anthem Traditional PPO and Value PPO both feature medical coverage administered by Anthem. The Value PPO has the lowest premiums, covers the same wide range of health care services and uses the same network of providers as the Traditional PPO, but has a higher annual deductible with lower premiums. Per IRS rules, Value PPO participants are able to take advantage of a Health Savings Account.
With an Anthem PPO, you decide whether to see a network-participating provider or go outside the network each time you need medical care. Both plans have in- and out-of-network deductibles, which apply to eligible medical and prescription drug expenses.
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, go to the Amgen Benefits Center and view the Summary Plan Description). To provide financial protection, the plans have a calendar-year out-of-pocket maximum based on your annual base pay. If you reach the out-of-pocket maximum, eligible expenses are covered at 100% for the remainder of the year. However, most people do not reach their out-of-pocket maximum(s) in any given year.
Prescription Drugs
Prescription drug coverage is administered by Express Scripts. You pay fixed copays for your prescription drugs, though you may first need to meet the medical plan deductible depending on your choice of medical plan. The plan includes mandatory generics. If your doctor feels the brand name drug is medically necessary, you will be responsible for the difference in cost between the plan’s generic cost and the cost of the brand name therapy.
Traditional PPO and Value PPO Plan Comparison
| Traditional PPO | Value PPO | |||
|---|---|---|---|---|
| Deductibles1 | ||||
| Coverage | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Staff member only | $500 | $850 | $1,650 | $3,200 |
| Family | $1,000 | $1,700 | $3,300 | $6,400 |
| Are prescription drugs included in the deductible? | No | No | Yes | Yes |
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| Medical and Prescription Drug Out-of-Pocket Maximums | ||||
| Annual Base Pay | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Less than $100,000 | $3,500/staff member only $7,000/family |
$8,000/staff member only $16,000/family |
$3,500/staff member only $7,000/family |
$8,000/staff member only $16,000/family |
| $100,000–$199,999 | $4,500/staff member only $7,850/family |
$10,500/staff member only $21,000/family |
$4,500/staff member only $7,850/family |
$10,500/staff member only $21,000/family |
| $200,000+ | $5,500/staff member only $7,850/family |
$13,000/staff member only $26,000/family |
$5,500/staff member only $7,850/family |
$13,000/staff member only $26,000/family |
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| Medical Coinsurance | In-Network | Out-of-Network2 | In-Network | Out-of-Network2 |
| Amgen’s share for most covered services | 80% | 50% after deductible | 80% | 50% after deductible |
| Preventive | 100% deductible waived | 50% after deductible | 100% deductible waived | 50% after deductible |
| Primary care (including OB/GYN visit3 or LiveHealth Online) | 100% after deductible | 50% after deductible | 100% after deductible | 50% after deductible |
| Specialist visit | 80% after deductible | 50% after deductible | 80% after deductible | 50% after deductible |
| Inpatient hospital stay | 80% after deductible | 50% after deductible | 80% after deductible | 50% after deductible |
| Outpatient surgery | 80% after deductible | 50% after deductible | 80% after deductible | 50% after deductible |
| Emergency room visit | 80% after deductible | 50% after deductible | 80% after deductible | 50% after deductible |
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| Prescription Drug Copays5,6 | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Preventive | 100% covered, deductible waived | 100% covered, deductible waived | 100% covered, deductible waived | 100% covered, deductible waived |
| Amgen products4 | 100% covered, deductible waived | 100% covered, deductible waived | 100% covered, after deductible | 100% covered, after deductible |
| Retail (up to 30-day supply) |
You pay $10 (generic); $30 (preferred/brand formulary); $50 (brand non-formulary) deductible waived | 50% covered, after deductible | 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) deductible waived |
Not covered | You pay $25 (generic); $75 (preferred/brand formulary); $125 (brand non-formulary) after deductible |
Not covered |
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- Only in-network eligible expenses apply toward your in-network deductible and in-network out-of-pocket maximum. Some expenses do not apply to your in-network deductible or in-network out-of-pocket maximum. Only out-of-network eligible expenses apply toward your out-of-network deductible and out-of-network out-of-pocket maximum. For more information, visit the Amgen Benefits Center and download the Summary Plan Description (SPD).
- For professional and outpatient facility charges, out-of-network benefits are reduced to one-half of 150% of the Medicare Prevailing Rate. 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 reimbursements are based on usual and prevailing rates as determined by the respective insurer/Administrator, and you may be balance-billed for the difference.
- 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% (deductible waived) under the Traditional PPO, and 100% after deductible under the Value PPO. Amgen branded products are not automatically covered by our plans. They are subject to applicable clinical guidelines and medical necessity, just as other drugs covered by our plans.
- Excluded: Compound medication ingredients that have not shown clinical benefit over lower-cost alternatives, have components that are not FDA approved, or have bulk ingredients used in compound medications where a standard equivalent exists.
- Formulary and dispensing rules are subject to change.