Medical Plans
Anthem PPO
PPO Summary
| In Network |
Out of Network Provider
|
||
|---|---|---|---|
| Annual Deductible - Individual/Family | $500/$1000 | $1,500/$3,000 | |
| Coinsurance (plan pays) | 90% | 60% | |
| Medical out of pocket maximum - Individual/Family | $2,500/$5,000 | $5,000/$15,000 | |
| Office visit - Primary Care, Specialist, Virtual (telemedicine/telehealth visits) | $20 copay | 40% coinsurance after deductible | |
| LiveHealth Online virtual visit | $0 PCP/$20 specialist | $0 PCP/$20 specialist | |
| Preventive care | no charge | 40% coinsurance | |
|
Hospitalization - Inpatient or Outpatient |
10% coinsurance after deductible | 40% coinsurance after deductible | |
| Lab and X-Ray | 10% coinsurance after deductible | 40% coinsurance after deductible | |
| Urgent Care | $20 copay | 40% coinsurance after deductible | |
| Emergency Services | 10% coinsurance after deductible | 40% coinsurance after deductible | |
| Chiropractic | $20/visit / 30 visits | 40% coinsurance | |
| Pharmacy - | |||
| Pharmacy Out of Pocket Maximum - Individual/Family | $750/$2,250 | $750/$2,250 | |
|
Retail Pharmacy (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 |
$10 $20 $50 $20% to $200 |
50% up to $250 per prescription, deductible does not apply |
|
|
Mail Order (90-day supply, except Tier 4) Tier 1 Tier 2 Tier 3 Tier 4 (30-day supply) |
$20 $40 $100 20% to $200 |
not covered |
|
| Mental Health/Substance Abuse Benefits | |||
| Outpatient Office Visit/Facility Visit | $20 copay | 40% coinsurance after deductible | |
| Inpatient Hospital/Facility Fees | no charge | 40% coinsurance after deductible | |
| Inpatient Hospital/Doctor & other services | no charge | 40% coinsurance after deductible | |
Links
Anthem EPO
EPO Summary
| In Network | |
|---|---|
| Annual Deductible - Individual/Family | $350/$700 |
| Coinsurance (plan pays) | 90% |
| Medical out of pocket maximum - Individual/Family | $2,500/$5,000 |
| Office visit - Primary Care, Specialist, Virtual (telemedicine/telehealth visits) | $20 copay |
| LiveHealth Online virtual visit | $0 PCP/$20 specialist |
| Preventive care | no charge |
|
Hospitalization - Inpatient or Outpatient |
10% coinsurance after deductible |
| Lab and X-Ray | 10% coinsurance after deductible |
| Urgent Care | $20 copay |
| Emergency Services | 10% coinsurance after deductible |
| Chiropractic | $20/visit / 30 visits |
| Pharmacy - | |
| Pharmacy Out of Pocket Maximum - Individual/Family | $750/$2,250 |
|
Retail Pharmacy (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 |
$10 $20 $50 $20% to $200 |
|
Mail Order (90-day supply, except Tier 4) Tier 1 Tier 2 Tier 3 Tier 4 (30-day supply) |
$20 $40 $100 20% to $200 |
| Mental Health/Substance Abuse Benefits | |
| Outpatient Office Visit/Facility Visit | $20 copay |
| Inpatient Hospital/Facility Fees | no charge |
| Inpatient Hospital/Doctor & other services | no charge |
Links
Anthem Vivity & Select HMO
Vivity & Select HMO Summary
Vivity and Select plan designs are the same. They differ in the medical groups that are included in each plan.
| In Network | |
|---|---|
| Annual Deductible - Individual/Family | None |
| Coinsurance (plan pays) | 100% |
| Medical out of pocket maximum - Individual/Family | $1,000/$2,000 |
| Office visit - Primary Care, Specialist, Virtual (telemedicine/telehealth visits) | $10 copay |
| LiveHealth Online virtual visit | $0 PCP/$10 specialist |
| Preventive care | no charge |
|
Hospitalization - Inpatient Outpatient |
$250 copay per admit $100 copay per visit |
| Lab and X-Ray | no charge |
| Urgent Care | $10 copay |
| Emergency Services | $100 copay |
| Chiropractic | $10/visit / 30 visits |
| Pharmacy - | |
| Pharmacy Out of Pocket Maximum - Individual/Family | combined with medical out of pocket max |
|
Retail Pharmacy (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 |
$10 $20 $50 $20% to $200 |
|
Mail Order (90-day supply, except Tier 4) Tier 1 Tier 2 Tier 3 Tier 4 (30-day supply) |
$20 $40 $100 20% to $200 |
| Mental Health/Substance Abuse Benefits | |
| Outpatient Office Visit/Facility Visit | $10 copay |
| Inpatient Hospital/Facility Fees | no charge |
| Inpatient Hospital/Doctor & other services | no charge |
Links
Anthem California Care HMO
California Care HMO Summary
| In Network | |
|---|---|
| Annual Deductible - Individual/Family | None |
| Coinsurance (plan pays) | 100% |
| Medical out of pocket maximum - Individual/Family | $1,000/$2,000 |
| Office visit - Primary Care, Specialist, Virtual (telemedicine/telehealth visits) | $15 copay |
| LiveHealth Online virtual visit | $0 PCP/$15 specialist |
| Preventive care | no charge |
|
Hospitalization - Inpatient Outpatient |
$250 copay per admit $100 copay per visit |
| Lab and X-Ray | no charge |
| Urgent Care | $15 copay |
| Emergency Services | $100 copay |
| Chiropractic | $15/visit / 30 visits |
| Pharmacy - | |
| Pharmacy Out of Pocket Maximum - Individual/Family | combined with medical out of pocket max |
|
Retail Pharmacy (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 |
$10 $20 $50 $20% to $200 |
|
Mail Order (90-day supply, except Tier 4) Tier 1 Tier 2 Tier 3 Tier 4 (30-day supply) |
$20 $40 $100 20% to $200 |
| Mental Health/Substance Abuse Benefits | |
| Outpatient Office Visit/Facility Visit | $15 copay |
| Inpatient Hospital/Facility Fees | no charge |
| Inpatient Hospital/Doctor & other services | no charge |
Links
For full plan summaries, please contact the Benefits Department at (949) 580-3424 or email benefits@svusd.org.