Medical
Xavier offers two health insurance plans through Anthem. You choose the plan that is best for you and your family. Option 1 is the Traditional PPO and Option 2 is the High Deductible Health Plan (HDHP) with a Health Savings Account. Both plans include pharmacy coverage. Pharmacy copays and co-insurance do apply to the dedcutible and out-of-pocket maximum.
Within both plans are three tiers of coverage. Tier 1 and 2 are both in-network coverage while Tier 3 is out-of-network coverage. Tier 1 offers the best discounts and a lower deductible/co-insurance. Tier 2 offers moderate discounts and a slightly higher deductible/coinsurance. Below you will find the in-network coverage (Tier 1 and Tier 2) details:
| PPO Tier 1 | PPO Tier 2 | HDHP Tier 1 | HDHP Tier 2 | |
| Deductible | $750 single / $1,500 family | $1,250 single / $2,500 family | $3,200 single / $6,400 family | $3,500 single / $7,000 family |
| Co-insurance | 90%/10% | 80%/20% | 90%/10% | 80%/20% |
| Out-of-Pocket Maximum | $2,000 single / $4,000 family | $2,000 single / $4,000 family | $4,000 single / $8,000 family | $4,000 single / $8,000 family |
| PCP/Specialist Office Visit | $20/$40 | $20/$40 | Ded. then 10% | Ded. then 20% |
| Inpatient Hospital | Ded. then 10% | Ded. then 20% | Ded. then 10% | Ded. then 20% |
| Outpatient Hospital | Ded. then 10% | Ded. then 20% | Ded. then 10% | Ded. then 20% |
| Emergency Room | $150 copay | $150 copay | Ded. then 10% | Ded. then 20% |
| Urgent Care Facility | $35 copay | $35 copay | Ded. then 10% | Ded. then 20% |
Use these instructions to find the Tier of your provider or facility.
Summary of Benefits
Both Anthem plans cover preventative care, screenings, and immunizations as well as preventative care for chronic conditions (per IRS guidelines) at 100% with in-network providers. For information on other care and services, review the following:
Summary of Benefits - PPO
Summary of Benefits - HDHP
Benefit Booklet - PPO
Benefit Booklet - HDHP
Pharmacy
Both Anthem plans include pharmacy drug coverage. The Anthem formulary includes 4 tiers of drugs: Generic, Brand, Non-Preferred Brand, and Speciality. In-network coverage for each tier is as follows:
| Tier | PPO (30/90 day copays) | HDHP (coinsurance) |
| 1 - Generic | $15/$30 | Deductible then 10% |
| 2 - Brand | $40/$100 | Deductible then 10% |
| 3 - Non Preferred Brand | $60/$150 | Deductible then 10% |
| 4 - Speciality | 25% up to $250 (30 day-supply) | Deductible then 10% |
This applies to all retail pharmacies, excluding Walgreens. Employees may also opt for mail-order prescriptions through CarelonRx.
Employees may use Anthem's drug search to determine where their prescriptions fall in the formulary and if prior authorization or step therapy are required.
Anthem Contact Information
(844) 714-6012
www.anthem.com
Group Number
PPO - OH2061M010
HDHP - OH2061M011
Sydney Health
Use Anthem’s Sydney App to find which tier your providers are in, check costs, review benefits and view/email your ID card. The app is available for download on iOS and Android phones. Need help or have questions? Call (844) 714-6012.
Travel Coverage
The Anthem BlueCard PPO Program provides access to care across the U.S. as well as internationally. View for more on the BlueCard PPO Program or call (844) 714-6012. In-network providers will submit the claim on your behalf. With out-of-network providers, you may need to submit your own international claim form.