Indiana University

University Human Resource Services

Compare 2014 Medical Care Plans Distinguishing Features

 

HDHP PPO & Health Savings Account (HSA)
PPO $500 Deductible
PPO $900 Deductible
IU Health Quality Partners (IUHQP)
Residency Requirement No 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.
Provider Network Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide and overseas PPO network. Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide and overseas PPO network. Full benefits from Anthem Blue Access and Blue Card PPO providers in a nationwide and overseas PPO network. Benefits only from IUHQP providers. Designation of a Primary Care Physician (PCP) is required.
HSA Contributions IU Contribution
$1,250 for employee only coverage and $2,500 if family members are covered. Contribution is deposited with the employee's second January paycheck.

Employee Contribution
$300 ($25 monthly) minimum up to $3,300 individual/$6,550 all other coverage levels; for those age 55+, an additional $1,000 catch-up.
Not applicable. Not applicable. Not applicable.
Medical        
In-Network Benefits        
Deductibles $1,250 employee only/$2,500 all other coverage levels. Applies to all services except preventive medical services and preventive prescriptions. $500 individual/$1,500 family maximum deductible. $900 individual/$2,700 family maximum deductible. $500 employee only/$1,500 family maximum deductible.
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 equals $2,400 ($7,200 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.
Out-of-Network Benefits        
Deductibles $2,500 employee only/$5,000 all other coverage levels. $900 individual/$2,700 family maximum. $900 individual/$2,700 family maximum. No Out-of-Network benefits, except emergency.
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%.
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; 40% out of network. $75 co-pay per visit; 30% out of network after deduction. $75 co-pay per visit; 30% out of network after deduction. $75 co-pay per visit (paid as in-network when 50 miles from home).
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 Anthem Behavioral Health. Prior authorization is required. Covered as any other illness through IUHQP designated providers. 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.

Plan deductible applies, except for the preventive drug list.

(Specialty drugs only available through Mail Order.)
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.
Plan deductible applies, except for the preventive drug list.

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 fluoride, low dose aspirin, folic acid, Vitamin D for age 65 and older, and iron. 100% coverage for Tobacco cessation products and nicotine replacement (up to 180 day supply annually). Over the Counter products require a prescription for coverage.
Vision Care        
Exams and Eyewear Anthem Blue View Vision network for a routine eye exam ($10 co-pay) and eyewear (frames, lenses, and contacts) with specific allowances. (See enclosed summary for details.) One routine eye exam per year, plan pays 100% in-network. One routine eye exam per year, plan pays 100% in-network.