Indiana University

University Human Resource Services

Compare 2013 Medical Care Plans Distinguishing Features

HDHP PPO & HSA
PPO $900 Deductible
IU Health Quality Partners (IUHQP)
PPO $400 Deductible
Residency Requirement
No residency requirement. No residency requirement. Residents of Blackford, Boone, Brown, Carroll, Clinton, Delaware, Greene, Hamilton, Hancock, Hendricks, Henry, Howard, Johnson, Lawrence, Madison, Marion, Monroe, Morgan, Owen, Putnam, Shelby, Tipton, & Tippecanoe. No residency requirement.
Provider Network
Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide PPO network. Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide PPO network. Benefits only from IUHQP providers. Designation of a Primary Care Physician (PCP) is required. Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide PPO network.
IU Contribution to HSA
$1,250 for employee-only coverage; $2,500 if family members covered. (There is an annual $300 minimum employee contribution; no IU contribution for enrollments September 1 and after) Not applicable. Not applicable. Not applicable.
Medical
In-Network Benefits
Deductibles
$1,250 employee-only/$2,500 when family members are covered. Applies to all services except preventive medical services and preventive prescriptions. $900 individual/$2,700 family maximum. $400 deductible employee-only/$1,200 family coverage. $400 individual/$1,200 family maximum.
Co-insurance
After deductible, member pays 20%. After deductible, member pays 20%. After deductible, member pays 20%. After deductible, member pays 20%.
Out-of-Pocket Maximum
After the deductible and co-insurance together equal $2,500 ($5,000 family), then there is no co-insurance. After the deductible and co-insurance equal $2,400 ($7,200 family) then there is no co-insurance. After deductible, co-insurance equal $2,400 ($7,200 family), then there is no co-insurance. After the deductible and co-insurance equals $2,400 ($7,200 family), then there is no co-insurance.
Out-of-Network Benefits
 
Deductibles
$2,400 individual/$4,800 family maximum. $900 individual/$2,700 family maximum. No Out-of-Network benefits, except emergency. $900 individual/$2,700 family maximum.
Co-insurance
After deductible, member pays 40%. After deductible, member pays 30%. After deductible, member pays 30%.
Out-of-Pocket Maximum
After the deductible and co-insurance equals $5,000 ($10,000 family), then there is no co-insurance. After the deductible and co-insurance equals $3,000 ($9,000 family), then there is no co-insurance. After the deductible and co-insurance equals $3,000 ($9,000 family), then there is no co-insurance.
In-Network Preventive Services
Plan pays 100%. Plan pays 100%. Plan pays 100%. Plan pays 100%.
In-Network Routine Vision Exam
One eye exam per year, plan pays 100%. One eye exam per year, plan pays 100%. One eye exam per year, plan pays 100%. One eye exam per year, plan pays 100%.
Emergency Room
20% co-insurance after deductible. $150 co-pay per visit (waived if admitted) $150 co-pay per visit (waived if admitted) $150 co-pay per visit (waived if admitted)
Urgent Care
20% co-insurance after deductible. $75 co-pay per visit. $75 co-pay per visit. $75 co-pay per visit.
Mental Health
Covered as any other illness through Anthem Behavioral Health. Prior authorization is required. Covered as any other illness through Anthem Behavioral Health. Prior authorization is required. Covered as any other illness through IUHQP designated providers. Prior authorization is required. Covered as any other illness through Anthem Behavioral Health. Prior authorization is required.
Prescription Drugs
In-Network Co-insurance
Retail (up to 30-day supply):
20% co-insurance after deductible.

Mail Order
(up to 90-day supply):
20% co-insurance after deductible.

(Deductible does not apply to the preventive drug list.)
Retail (up to 30-day supply):
Tier 1 - $8
Tier 2 - $25
Tier 3 - $45
Mail Order (up to 90-day supply):
Tier 1 - $20
Tier 2 - $62
Tier 3 - $112
(Specialty drugs only available through Mail Order.)
Out-of-Network Co-insurance
Retail (up to 30-day supply):
40% co-insurance after deductible.

Mail Order
Not covered
Retail (up to 30-day supply):
50% co-insurance

Mail Order Not covered
Preventive Prescription Exceptions
(In-Network Only)
Plan pays 100% for generic contraceptives, pediatric sodium floride, low dose aspirin, folic acid, and iron. 100% coverage for Tobacco cessation products and nicotine replacement (up to 180 day supply annually).
Exclusions
Exclusion
(examples)
• Services not medically necessary as determined by the Plan Administrator • Custodial care, convalescent, “long-term” nursing, or residential care • Cosmetic surgery, procedures, and drugs • Services, supplies, and drugs for obesity or weight control, except surgery for morbid obesity • Supportive devices for the feet, and routine foot care • Immunizations and exams required as a condition of employment, for licensing, or for other purposes such as camps or travel • Experimental/Investigative services • Artificial insemination; fertilization (such as in-vitro, GIFT, ZIFT) or procedures and testing related to fertilization; reversal of sterilization; infertility drugs and related services following the diagnosis of infertility • Drugs, devices, or services related to sex transformation, male or female sexual or erectile dysfunction or inadequacy regardless of the cause • Drugs in excess of limits established by the plan • Non-sedating (3rd generation) antihistamines, such as Zyrtec and Allegra • Services and supplies used to treat conditions to the extent that, according to generally accepted Professional Standards, such conditions are not amenable to favorable modification through medical treatment • Sclerotherapy for the treatment of varicose veins of the lower extremities.