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Anthem Small Group Traditional PPO Medical and Prescription Plans - Indiana

Network - Insured's Cost Share
Non-Network - Insured's Cost Share
Plan
Office Co-pay
PCP / SPC1
Deductible2
Single / Family
Co-Insurance
after Deductible
Out-of-Pocket Max3
Single / Family
ER Co-pay4
Deductible2
Single / Family
Co-Insurance
after Deductible
Out-of-Pocket Max3
Single / Family
Rx Options

Option 1
$35 / $50
$5,000 / $15,000
30%
$10,000 / $20,000
$150 / 30%
$10,000 / $30,000
50%
$20,000 / $40,000
I, J, K
Option 2
$35 / $35
$5,000 / $15,000
30%
$10,000 / $20,000
$150 / 30%
$10,000 / $30,000
50%
$20,000 / $40,000
I, J, K
Option 3
$35 / $35
$5,000 / $15,000
20%
$10,000 / $20,000
$150 / 20%
$10,000 / $30,000
40%
$20,000 / $40,000
I, J, K
Option 4
$30 / $45
$3,000 / $9,000
30%
$6,000 / $12,000
$150 / 30%
$6,000 / $18,000
50%
$12,000 / $24,000
I, J, K
Option 5
$30 / $30
$3,000 / $9,000
30%
$6,000 / $12,000
$150 / 30%
$6,000 / $18,000
50%
$12,000 / $24,000
I, J, K
Option 6
$30 / $30
$2,500 / $7,500
30%
$6,000 / $12,000
$150 / 30%
$5,000 / $15,000
50%
$12,000 / $24,000
I, J, K
Option 7
$30 / $45
$2,500 / $7,500
20%
$6,000 / $12,000
$150 / 20%
$5,000 / $15,000
40%
$12,000 / $24,000
I, J, K
Option 8
$30 / $30
$2,500 / $7,500
20%
$6,000 / $12,000
$150 / 20%
$5,000 / $15,000
40%
$12,000 / $24,000
I, J, K
Option 9
$25 / $25
$2,000 / $6,000
30%
$5,000 / $10,000
$150 / 30%
$4,000 / $12,000
50%
$10,000 / $20,000
I, J, K
Option 10
$25 / $40
$1,500 / $4,500
30%
$5,000 / $10,000
$150 / 30%
$3,000 / $9,000
50%
$10,000 / $20,000
I, J, K
Option 11
$25 / $25
$1,500 / $4,500
30%
$5,000 / $10,000
$150 / 30%
$3,000 / $9,000
50%
$10,000 / $20,000
I, J, K
Option 12
$25 / $25
$2,000 / $6,000
20%
$5,000 / $10,000
$150 / 20%
$4,000 / $12,000
40%
$10,000 / $20,000
I, J, K
Option 13
$20 / $35
$1,000 / $3,000
30%
$5,000 / $10,000
$150 / 30%
$2,000 / $6,000
50%
$10,000 / $20,000
H, I, J, K
Option 14
$25 / $25
$1,500 / $4,500
20%
$5,000 / $10,000
$150 / 20%
$3,000 / $9,000
40%
$10,000 / $20,000
I, J, K
Option 15
$20 / $20
$1,000 / $3,000
30%
$5,000 / $10,000
$150 / 30%
$2,000 / $6,000
50%
$10,000 / $20,000
H, I, J, K
Option 16
$20 / $35
$1,000 / $3,000
20%
$4,000 / $8,000
$150 / 20%
$2,000 / $6,000
40%
$8,000 / $16,000
H, I, J, K
Option 17
$20 / $20
$1,000 / $3,000
20%
$4,000 / $8,000
$150 / 20%
$2,000 / $6,000
40%
$8,000 / $16,000
H, I, J, K
Option 18
$25 / $40
$2,000 / $6,000
0%
$2,000 / $6,000
$150 / 0%
$4,000 / $12,000
20%
$8,000 / $16,000
I, J, K
Option 19
$25 / $40
$500 / $1,500
20%
$3,000 / $6,000
$100 / 20%
$1,000 / $3,000
40%
$6,000 / $12,000
H, I, J, K
Option 20
$25 / $25
$500 / $1,500
20%
$3,000 / $6,000
$100 / 20%
$1,000 / $3,000
40%
$6,000 / $12,000
H, I, J, K
Option 21
$20 / $20
$1,000 / $3,000
10%
$3,000 / $6,000
$150 / 10%
$2,000 / $6,000
30%
$6,000 / $12,000
H, I, J, K
Option 22
$20 / $35
$500 / $1,500
20%
$2,500 / $5,000
$100 / 20%
$1,000 / $3,000
40%
$5,000 / $10,000
H, I, J, K
Option 23
$20 / $20
$500 / $1,500
20%
$2,500 / $5,000
$100 / 20%
$1,000 / $3,000
40%
$5,000 / $10,000
H, I, J, K
Option 24
$20 / $20
$500 / $1,500
10%
$2,500 / $5,000
$100 / 10%
$1,000 / $3,000
30%
$5,000 / $10,000
H, I, J, K
Option 25
$25 / $40
$1,000 / $3,000
0%
$1,000 / $2,000
$150 / 0%
$2,000 / $6,000
20%
$5,000 / $10,000
H, I, J, K
Option 26
$15 / $15
$250 / $750
20%
$1,500 / $3,000
$75 / 20%
$500 / $1,500
40%
$3,000 / $6,000
H, I, J, K
Option 27
$15 / $15
$250 / $750
10%
$1,500 / $3,000
$75 / 10%
$500 / $1,500
30%
$3,000 / $6,000
H, I, J, K
Option 28
$10 / $10
$250 / $750
10%
$750 / $1,500
$75 / 10%
$500 / $1,500
30%
$1,500 / $3,000
H, I, J, K
Option 29
30% / 30%
$500 / $1,500
30%
$5,000 / $10,000
30%
$1,000 / $3,000
50%
$10,000 / $20,000
I, J, K
Option 30
20% / 20%
$2,500 / 7,500
20%
$4,000 / $12,000
20%
$5,000 / $15,000
50%
$8,000 / $24,000
I, J, K
Option D14
$25 / $25
$2,000 / $4,000
20%
$5,000 / $10,000
$150 / 20%
$4,000 / $8,000
40%
$10,000 / $20,000
I, J, K
Option D15
$25 / $25
$1,500 / $3,000
20%
$5,000 / $10,000
$150 / 20%
$3,000 / $6,000
40%
$10,000 / $20,000
I, J, K
Option D16
$20 / $20
$1,000 / $2,000
30%
$5,000 / $10,000
$150 / 30%
$2,000 / $4,000
50%
$10,000 / $20,000
H, I, J, K
Option D17
$20 / $20
$1,000 / $2,000
20%
$4,000 / $8,000
$150 / 20%
$2,000 / $4,000
40%
$8,000 / $16,000
H, I, J, K
Option D18
$25 / $25
$500 / 1,000
20%
$3,000 / $6,000
$100 / 20%
$1,000 / $2,000
40%
$6,000 / $12,000
H, I, J, K
1 
"PCP" is Primary Care Physician.  "SPC" is Specialist Physician.
2
 
Deductible applies only to covered medical services listed with a  percentage (%) co-insurance.
However, the deductible does not apply to Emergency Room Services, where a percentage (%) co-insurance may apply to covered services.
3 
Out-of-Pocket Maximum equals sum of Deductible, Co-insurance Payments and Office Co-pays.
4 
Deductible does not apply to Emergency Room Services.  The Co-insurance percentage (%) applies after Co-pay.
Retail Pharmacy Benefits - 30 Day Supply (Insured's Cost Share)
 
Pharmacy
Plan H
Pharmacy
Plan I
Pharmacy
Plan J
Pharmacy
Plan K
Deductible
none
none
none
$2001
Tier 1
Generic
$10 co-pay
$10 co-pay
$10 co-pay
$15 co-pay

Tier 2
Formulary Brand
$25 co-pay
$30 co-pay
$40 co-pay
$40 co-pay

Tier 3
Non-Formulary Brand
$40 co-pay
$60 co-pay
$60 co-pay
$60 co-pay

Tier 42
Injectable Drugs
Included
Above
Included
Above
25% co-pay3

Included
Above
Non-Network
All Categories
50%
$40 min payment
50%
$60 min payment
50%
$60 min payment
50%
$60 min payment
Mail Order Pharmacy Benefits - 30 Day Supply (Insured's Cost Share)
 
Pharmacy
Plan H
Pharmacy
Plan I
Pharmacy
Plan J
Pharmacy
Plan K
Deductible
none
none
none
$2001
Tier 1
Generic
$20 co-pay
$20 co-pay
$20 co-pay
$30 co-pay

Tier 2
Formulary Brand
$65 co-pay
$75 co-pay
$100 co-pay
$100 co-pay

Tier 3
Non-Formulary Brand
$100 co-pay
$150 co-pay
$150 co-pay
$150 co-pay

Tier 42
Injectable Drugs
Included
Above
Included
Above
25% co-pay3

Included
Above
Non-Network
All Categories
Not covered
Not covered
Not covered
Not covered

1 
The $200 Plan K deductible does not apply to Tier 1 Generic prescriptions.  The $200 deductible applies to combined Retail and Mail Order expenses.
2 
For Plan H, Plan I and Plan K, injectable drugs are categorized as Tier 1, Tier 2 or Tier 3, depending on whether the injectable is generic, brand name, etc.
3 
Under Plan J, the 25% co-pay for Tier 4 drugs is subject to a $2500 calendar year out-pocket expense limit.  The $2500 out-of-pocket limit applies to combined Retail and Mail Order expenses.
These are benefit overviews, meant to be used for general comparison of Anthem small Group plan options.
For a more comprehensive description of benefits for plan options you want to evaluate more closely, contact MedPlan Access.
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