University Human Resource Services

Compare 2009 Medical Care Plan Highlights

	IU PPO $900 Deductible		Blue Preferred Primary POS		IU HDHP PPO & Medical Savings Plan
	view plan information >		view plan information >		view plan information >
Monthly Rates	Employee Contribution	With Additional IU Subsidy	Employee Contribution	With Additional IU Subsidy	Employee Contribution	With Additional IU Subsidy
Employee Only	$5.00	$3.50	$5.00	$3.50	$5.00	$3.50
Employee w/ Child(ren)	$10.00	$7.00	$10.00	$7.00	$10.00	$7.00
Employee w/ Spouse	$10.00	$7.00	$17.04	$11.93	$10.00	$7.00
Family	$39.74	$27.82	$76.42	$53.50	$10.00	$7.00
Annual IU Contribution to Health Savings Account	Not Applicable		Not Applicable		$250 for employee only coverage. $500 when family members are covered.
Provider Network	Full benefits from Anthem Blue Access Preferred Providers and Blue Card PPO providers in other states.		Full benefits for services provided by the member’s Anthem PCP or Blue Preferred network providers and certain Blue Card providers in other states.		Full benefits from Anthem Blue Access Preferred Providers and Blue Card PPO providers in other states.
Maximum Allowable Amount	Benefits for covered services are based on the Maximum Allowable Amount (sometimes called Usual & Reasonable), which is the maximum amount the Plan will pay for a given service. Network providers have agreed to accept the Maximum Allowable Amount as payment in full. When you use a Non-Network Provider you are responsible for any balance due between the Non-Network Provider’s charge and the Maximum Allowable Amount in addition to any coinsurance, copayments, deductibles, and non-covered charges.
Primary Care Physician (PCP)	PCP not required		Must select PCP at enrollment		PCP not required
MEDICAL
In-Network Benefits:
Deductibles	$900 individual/$2,700 family maximum.		No deductible.		$1,150 employee-only/$2,300 when family members are covered (applies to all services except wellness.)
Co-pays	After deductible, member pays 10% copay.		$25 per office visit. $250 per hospital admission. $100 per outpatient facility visit.		After deductible, member pays 20% copay.
Out-of-Pocket Maximum	When deductible plus copays equal $2,400 individual ($6,700 family maximum) then there is no copay.		When copays equal $2,000 ($5,000 family maximum), then there is no copay.		When deductible plus copays equal $2,500 ($5,000 family maximum), then there is no copay.
Out-of-Network Benefits:
Deductibles	$900 individual/$2,700 family maximum.		$500 individual/$1,000 family maximum.		$2,300 individual/$4,600 family maximum.
Co-pays	After deductible, member pays 30% copay.		After deductible, member pays 30%.		After deductible, member pays 40%.
Out-of-Pocket Maximum	When deductible plus copays equal $2,400 ($6,700 family maximum), then there is no copay.		When deductible plus copays equal $5,000 ($10,000 family maximum), then there is no copay. Patient pays all amounts above U&R.		When deductible plus copays equal $5,000 ($10,000 family maximum), then there is no copay.
Wellness Services	Covered with copay.		Covered with copay.		Covered with copay.
Vision	One routine eye exam per year, with copay.		One routine eye exam per year, with copay.		One routine eye exam per year, with copay.
Emergency Room and Urgent Care Facility	$100 copay per ER visit. 10% copay per Urgent Care visit after deductible is met.		$100 copay per visit. $40 copay per Urgent Care Facility visit.		20% in-network copay after deductible (40% out-of-network).
PRESCRIPTION DRUGS (Rx)
In-Network copays	Retail (up to 30-day supply): $8 generic Rx $20 brand, low cost Rx (up to $65) $40 brand, high cost Rx ($65 or more) 100% non-covered Rx (with plan discounts)		Retail (up to 30-day supply): $8 formulary generic Rx $20 formulary brand Rx $40 non-formulary Rx		Retail (up to 30-day supply): 20% copay after deductible.
	Mail Order (up to 90-day supply): $20 generic Rx $45 brand, low cost Rx $90 brand, high cost Rx 100% non-covered Rx (with plan discounts)		Mail Order (up to 90-day supply): $20 formulary generic Rx $45 formulary brand Rx $90 non-formulary Rx		Mail Order (up to 90-day supply): 20% copay after deductible.
	**Brand costs are higher when generic is available.
Out-of-Network copays	50% of Maximum Allowable Amount.		50% of Maximum Allowable Amount.		40% copay after deductible.
MENTAL HEALTH
Mental Health	Full benefits from IU Psychiatric Management Providers. All services must have prior authorization. See plan summary for copays and deductibles.		Full benefits from Anthem Behavioral Health network providers. All services must have prior authorization. See plan summary for copays and deductibles.		20% copay after deductible for Anthem Behavioral Health network providers. All services must have prior authorization.

Page updated: 2 February 2009
UNIVERSITY HUMAN RESOURCE SERVICES
Poplars E165, 400 E. 7th St., Bloomington, IN 47405 • (812) 855-2172
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