Medical Plans
Highlights

Medical Plan Highlights

The U.S. Health Plan offers you a choice of two comprehensive medical plans to best fit your family’s needs.

Anthem Plans and Network

  • High Deductible Health Plan (HDHP)
  • Traditional Preferred Provider Organization Option (PPO)

With both plans you have the freedom to see any doctor nationwide. However, staying in the Anthem provider network will maximize savings and allow the plan to pay for portions of certain services before meeting the deductible. You can also utilize tax-advantaged accounts such as an HSA or FSA  to help pay for medical costs with pre-tax funds.

To locate participating providers and in-network pharmacies for both of our medical plan options, go to Find Care & Estimate Costs for Doctors Near You | Anthem.com and search under the following network names:

  • CA: Blue Cross PPO (Prudent Buyer)
  • Non-CA: National PPO (Blue Card PPO)

Medical Plans Summary

Below is a summary of the benefits included with the HDHP and PPO plan options.

 

Under the HDHP, you must satisfy the annual deductible before the U.S. Health Plan pays, including pharmacy. The only exception to this is certain preventive care which is not subject to the deductible when received in-network. If you are enrolled in the HDHP, and meet certain requirements, you are eligible to contribute to a Health Savings Account (HSA). An HSA is a bank account that allows you to set aside money on a pre-tax basis to pay for future qualified medical expenses.

* When using out-of-network providers you will be responsible for the indicated percentage of the allowed amount plus the entire cost in excess of what Anthem determines a typical network provider would have charged.
** Deductibles cross-accumulate. Claims will be applied toward both your in-network and out-of-network deductible amounts.
You may review the official Plan Document/SPD and other benefits on the Benefits Portal

Under the PPO, you must satisfy the deductible, except for those services for which there is a copay. Medical and Rx copays do not apply to the deductible but do apply to your out-of-pocket maximum.

* When using out-of-network providers you will be responsible for the indicated percentage of the allowed amount plus the entire cost in excess of what Anthem determines a typical network provider would have charged.
** Deductibles cross-accumulate. Claims will be applied toward both your in-network and out-of-network deductible amounts.
*** Deductible is waived for office visit and other services (e.g., lab, x-rays, injections) provided in an office setting.
**** Additional details applicable to brand drug prescription coverage are available in your Anthem Benefit Booklet.
You may review the official Plan Document/SPD and other benefits on the Benefits Portal.

What You Pay
In-Network
Out-of-Network*
Calendar Year Deductible**
Individual: $500
Individual + Family: $1,000
Individual: $3,500
Individual + Family: $7,000
Calendar Year Out-of-Pocket Maximum
Individual: $2,500
Individual + Family: $5,000
Individual: $5,000
Individual + Family: $10,000
Outpatient Services
Your cost after deductible
Your cost after deductible
Physician Office Visits***
$30 primary care/$45 specialist, deductible waived
30%
Routine Physical Examinations
(Preventive Care)
$30 copay, deductible waived, except certain preventive care that is free
30%
Diagnostic X-Ray and Lab
$10 copay, deductible waived
30%
Advanced Imaging (CT, MRI, PET, etc.)
$100 copay, deductible waived
30%
Outpatient Surgery
10%
30%
(+$500 if you fail to secure required pre-certification)
Hospital Benefits
Your cost after deductible
Your cost after deductible
Inpatient Hospitalization
$500 per confinement + 10%
$1,000 per confinement + 30% of balance (+$500 if you fail to secure required pre-certification)
Emergency Care
Emergency visit: $150 copay, deductible waived
Non-emergency visit: 10% after deductible
Emergency visit: $150 copay, deductible waived
Non-emergency visit: 30% after deductible
Prescription Drugs**** (per 30 day supply)
Your cost after deductible
Your cost after deductible
Generics
$10 copay
Not Covered
Preferred Brand Drugs
$50 copay
Not Covered
Non-Preferred Brand Drugs
$75 copay
Not Covered
Specialty Drugs
25% after deductible up to $300 per prescription
Not Covered
What You Pay
In-Network
Out-of-Network*
Calendar Year Deductible**
Individual: $1,750
Individual + Family: $3,500
Individual: $3,500
Individual + Family: $7,000
Calendar Year Out-of-Pocket Maximum
Individual: $3,500
Individual + Family: $7,000
Individual: $7,000
Individual + Family: $14,000
Outpatient Services
Your cost after deductible
Your cost after deductible
Physician Office Visits
10%
30%
Routine Physical Examinations
(Preventive Care)
10% except certain preventive care that is free
30%
Diagnostic X-Ray and Lab
10%
30%
Outpatient Surgery
10%
30%
(+$500 if you fail to secure required pre-certification)
Hospital Benefits
Your cost after deductible
Your cost after deductible
Inpatient Hospitalization
$500 per confinement + 10%
$1,000 per confinement + 30% of balance (+$500 if you fail to secure required pre-certification)
Emergency Care
10%
30% of PPACA-specified amount + 100% of the balance of charges if a non-emergency visit
Prescription Drugs
Your cost after deductible
Your cost after deductible
Generics
10%
You must pay the in-network percentage charge plus the entire cost in excess of what Anthem determines a typical network pharmacy would have charged
Preferred Brand Drugs
25%
You must pay the in-network percentage charge plus the entire cost in excess of what Anthem determines a typical network pharmacy would have charged
Non-Preferred Brand Drugs
40%
You must pay the in-network percentage charge plus the entire cost in excess of what Anthem determines a typical network pharmacy would have charged
Specialty Drugs
Coinsurance applies for generic or brand drugs as noted above; after your first specialty prescription fill, you must use the Carelon Specialty Pharmacy or your prescription costs will not be covered
Not Covered

Anthem

www.anthem.com/ca
(833) 549-1192
Contact Anthem to find a provider or for help with medical and pharmacy benefits, virtual care (Live Health) and the 24/7 Nurseline.

Key Benefits Contacts
Plan Documents and Notices
2025 Benefits Guide
2024 Benefits Guide
2025 Semi-Monthly Rates
HDHP Plan Booklet
PPO Plan Booklet