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Browse the various medical and infertility treatment benefits to understand the difference between the two tiers.
|BENEFIT||TIER 1||TIER 2|
|USC VHH/Keck Medicine of USC/ USC Care Medical Group||Anthem Blue Cross Prudent BuyerNetwork/ BlueCard® Providers|
|Deductible: Individual / Family||None||$500/$750|
|Out-of-pocket maximum (medical)||$5,000 individual/$10,000 employee and all covered dependents combined|
|Physician office visit||Plan pays 100% after $10 copay(USC Care Medical Group only)||Plan pays 100% after $25 copay(deductible waived)|
|Preventive care (adult and child)||Plan pays 100%||Plan pays 100% (deductible waived)|
|Child immunizations (through age 18)||Plan pays 100%||Plan pays 100% (deductible waived)|
|Maternity – physician office visit||Plan pays 100% after $10 copay(USC Care Medical Group only)||Plan pays 100% after $25 copay(deductible waived)|
|Maternity – physician delivery||Plan pays 100%||Plan pays 70%|
|Maternity – hospital charges||Plan pays 100%||Plan pays 70%|
|(up to 120 days /calendar year)|
|Home health care||Plan pays 70%|
|(up to 50 days /calendar year)|
|Durable medical equipment||Plan pays 90%||Plan pays 70%|
|Hospice care||Plan pays 80%|
|Mental health/substance abuse –Inpatient room and board||Plan pays 100%||Plan pays 70%|
|Mental health/substance abuse –Outpatient||Plan pays 100% after $10 copay(USC Care Medical Group only)||Plan pays 100% after $25 copay(deductible waived)|
|Prescription drugs||USC VHH Pharmacies(90-day supply) Generic: You pay 10% up to $5 max Brand Name: You pay 20% Non-Formulary: You pay 30%||Navitus Pharmacies(30-day supply) Generic: You 20% up to $10 max Brand Name: You pay 30% Non-Formulary: You pay 50%|
|Out-of-pocket maximum Prescription: Individual/Family||$1,600 individual / $3,200 employee and all covered dependents|
|TIER 1||TIER 2|
|USC VHH/Keck Medicine of USC/USC Care Medical Group||Anthem Blue Cross Prudent Buyer Network/ BlueCard® Providers|
|Medical – Lifetime Maximum||$10,000 lifetime maximum|
|Physician Office Visit||$10 copay||$25 copay|
|Artificial Insemination||20% coinsurance|
|Invitro Fertilization (IVF)||20% coinsurance|
|Physician Services||20% coinsurance|
|Imaging, Tests and Lab Work||20% coinsurance|
- Screening and testing – The health plan will pay 100% for only medically necessary screening and testing of COVID-19. Beginning Saturday, Jan. 15, 2022, members covered by private health insurance or a group health plan are now able to purchase over-the-counter (OTC) COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA) at no cost without a prescription. The reimbursement of OTC COVID-19 tests will remain in effect until the Public Health Emergency (PHE) is rescinded.
- COVID-19 test kits can be purchased at network pharmacies at $0 member out-of-pocket, with a quantity limit of eight tests per covered individual every 30 days. This eight-test limit does not apply to such test kits ordered with a prescription. COVID-19 tests kits must be purchased at the pharmacy counter with your medical/rx insurance card to ensure that they are processed properly. View Navitus’ list of network pharmacies.
- Members can also submit a claim for reimbursement for COVID-19 OTC test kits purchased on or after Jan. 15, including those from non-network pharmacies and non-pharmacy locations. The COVID-19 OTC Test Claim Form is also available for download at navitus.com/members. For more detailed information, please view the COVID OTC Testing FAQs.
- Please see the Coronavirus FAQ and the Coronavirus member information.
- Your Anthem health plan will cover the care you receive if you’re diagnosed with COVID-19. Anthem will also waive out-of-pocket expenses for the focused test used to diagnose COVID-19.
- Visit anthem.com/ca/blog or the CDC website at cdc.gov/coronavirus to learn more.
HealthComp | www.healthcomp.com
Navitus | www.navitus.com (prescriptions)