PPO Medical Plans

The Anthem Traditional PPO and Value PPO both feature medical coverage administered by Anthem and prescription drug coverage administered by Express Scripts. The Value PPO has lower premiums, covers the same wide range of healthcare services and uses the same network of providers, but it has a higher annual deductible—per IRS rules—to be able to take advantage of a Health Savings Account. 

With an Anthem PPO, you decide whether to see a network-participating provider or go outside the network each time you need medical care. You do not need to choose a primary care physician (PCP) to coordinate your care. Both plans have in- and out-of-network deductibles, which apply to eligible medical and prescription drug expenses. (Eligible in-network preventive care, including well-woman care, is covered at 100% and not subject to the deductible.)

After you satisfy the in-network deductible, eligible medical expenses are covered at 100% or 80%, depending on the service. After you satisfy the out-of-network deductible, eligible expenses are generally covered at 50% (for exceptions, go to the Amgen Benefits Center and view the Summary Plan Description). You pay fixed copays for your prescription drugs, though you may first need to meet the medical plan deductible depending on your choice of medical plan. The plan includes mandatory generics. If your doctor feels the brand name drug is medically necessary for you, you may continue to utilize it, but you will be responsible for the difference in cost between the plan’s generic cost and the cost of the brand name therapy.

Traditional PPO vs. Value PPO Plans

  Traditional PPO Value PPO
Deductibles1
Coverage In-Network Out-of-Network In-Network Out-of-Network
Staff member only $500 $850 $1,600 $3,200
Family $1,000 $1,700 $3,200 $6,400
Are prescription drugs included in the deductible? No No Yes Yes
Medical and Prescription Drug Out-of-Pocket Maximums
Annual Base Pay In-Network Out-of-Network In-Network Out-of-Network
Less than $100,000 $3,500/staff member only
$7,000/family		 $8,000/staff member only
$16,000/family		 $3,500/staff member only
$7,000/family		 $8,000/staff member only
$16,000/family
$100,000–$199,999 $4,500/staff member only
$7,850/family		 $10,500/staff member only
$21,000/family		 $4,500/staff member only
$7,850/family		 $10,500/staff member only
$21,000/family
$200,000+ $5,500/staff member only
$7,850/family		 $13,000/staff member only
$26,000/family		 $5,500/staff member only
$7,850/family		 $13,000/staff member only
$26,000/family
Medical Coinsurance In-Network Out-of-Network2 In-Network Out-of-Network2
Amgen’s share for most covered services 80% 50% after deductible 80% 50% after deductible
Preventive 100% deductible waived 50% after deductible 100% deductible waived 50% after deductible
Primary care (including OB/GYN visit3 or LiveHealth Online) 100% after deductible 50% after deductible 100% after deductible 50% after deductible
Specialist visit 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Inpatient hospital stay 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Outpatient surgery 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Emergency room visit 80% after deductible 50% after deductible 80% after deductible 50% after deductible
Prescription Drug Copays5,6 In-Network Out-of-Network In-Network Out-of-Network
Preventive 100% covered, deductible waived 100% covered, deductible waived 100% covered, deductible waived 100% covered, deductible waived
Amgen products4 100% covered, deductible waived 100% covered, deductible waived 100% covered, after deductible 100% covered, after deductible
Retail
(up to 30-day supply)		 You pay $10 (generic); $30 (preferred/brand formulary); $50 (brand non-formulary) deductible waived 50% covered, after deductible You pay $10 (generic); $30 (preferred/brand formulary); $50 (brand non-formulary)
after deductible		 50% covered, after deductible
Mail-order
(up to 90-day supply)		 You pay $25 (generic); $75 (preferred/brand formulary); $125 (brand non-formulary)
deductible waived		 Not covered You pay $25 (generic); $75 (preferred/brand formulary); $125 (brand non-formulary)
after deductible		 Not covered
  1. Only in-network eligible expenses apply toward your in-network deductible and in-network out-of-pocket maximum. Some expenses do not apply to your in-network deductible or in-network out-of-pocket maximum. Only out-of-network eligible expenses apply toward your out-of-network deductible and out-of-network out-of-pocket maximum. For more information, visit MyHR and download the Summary Plan Description (SPD).
  2. For professional and outpatient facility charges, out-of-network benefits are reduced to one-half of 150% of the Medicare Prevailing Rate. In addition to satisfying a higher deductible, paying a higher coinsurance rate, and being subject to higher out-of-pocket maximums, out-of-network benefits reimbursements are based on usual and prevailing rates as determined by the respective insurer/Administrator, and you may be balance-billed for the difference.
  3. Eligible in-network preventive care, including well-woman care, is covered at 100% before the deductible.
  4. Electing an Anthem medical plan will ensure coverage for Amgen products. Amgen products are covered at 100% (deductible waived) under the Traditional PPO, and 100% after deductible under the Value PPO.
  5. Excluded: Compound medication ingredients that have not shown clinical benefit over lower-cost alternatives, have components that are not FDA approved, or have bulk ingredients used in compound medications where a standard equivalent exists.
  6. Formulary and dispensing rules are subject to change.