Benefits Guides
Faculty, Administrators, AFSCME 3200 & FOP
Review the Cost Sharing Summary for a detailed listing of deductibles, co-insurance, plan year maximums and office visit co-pays. Expand the PPO Medical Plan Coverage Chart (Alphabetical Listing) heading to view a listing of the in-network and out-of-network coverage for a variety of categories.
AFSCME 3200 and FOP members: the Collective Bargaining Agreement will supersede the following information in case of discrepancies.
PPO Medical Plan and Prescription Cost Sharing Summary
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Deductible The member must pay all costs up to this amount before the plan begins to pay for covered services. Some specific services, such as preventive care, do not apply to the deductible. See the coverage chart for more details. In-network and Out-of-Network accrue separately. | $800/$1,600 Individual/ Family | $1,600/$3,200 Individual/ Family |
| Plan Co-Insurance A cost sharing feature in which the plan (Anthem Blue Cross Blue Shield) pays a fixed percentage of the cost of medical care. | 80% for most categories | 70% for most categories |
| Employee Co-Insurance A cost sharing feature in which the Member pays a fixed percentage of the cost of medical care. | 20% for most categories | 30% for most categories |
| Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) | No deductible $25 co-pay | Subject to deductible 70% reimbursement |
Plan Year Maximums
Out-of-pocket maximums accumulate separately; therefore, charges for out-of-network services cannot be applied to the in-network employee out-of-pocket maximum and vice versa
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Employee Co-Insurance Maximum Equal the total employees will pay for co-insurance during the plan year. | $2,700/$5,400 Individual/Family | $5,400/$10,800 Individual/Family |
| Employee Out-of-Pocket Maximum Equals the total employees will pay in deductibles and co-insurance during the plan year. | $3,500/$7,000 Individual/Family | $7,000/ $14,000 Individual/Family |
| Employee Office Visit Co-Pay Maximum Equals the total employees will pay for Office Visit co-pays during the plan year. | $2,325/$4,650 Individual/Family | Out of Network Co-Pay not applicable |
| Employee Prescription Co-Pay Maximum Equals the total employees will pay for Prescription co-pays during the plan year. | $2,000/$4,000 Individual/Family | Out of Network Co-Pay not applicable |
| Total Annual Out-of-Pocket Maximum | $7,850 / $15,650 | See Above |
Individual Lifetime Maximum Benefits, Unlimited
Prescription Drug Coverage
| Category | Retail Pharmacy | Mail Order Pharmacy |
|---|---|---|
| Generic Drug | $20 | $25 |
| Brand Name Formulary | $30 | $40 |
| Brand Name Non-Formulary | $40 | $55 |
Eligible Specialty Medications: 30% coinsurance or $0 copay if enrolled in PrudentRx Specialty Drug Program
PPO Medical Plan Coverage Chart (Alphabetical Listing)
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Ambulance (subject to medical necessity) | Subject to deductible 80% reimbursement | Paid as in-network |
| Child Wellness Visits Anthem Blue Cross and Blue Shield Standards | No deductible 100% reimbursement for eligible procedures | Subject to deductible 70% reimbursement |
| Chiropractic Services 12 visit limit per plan year | $25 co-pay | Subject to deductible 70% reimbursement |
| Durable Medical Equipment | Subject to deductible 80% reimbursement | Paid as in-network |
| Emergencies A medical emergency is defined by insurance company standards. May include a condition that if untreated could be life threatening or seriously impair bodily functions. | $50 co-pay The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit. | Paid as in-network |
| Gynecological Exams/PAP Smears Preventive and Diagnostic | $25 co-pay for office visit | No deductible 70% reimbursement |
| Hearing NOTE: Hearing medical conditions are covered the same as any other condition. | One routine hearing exam covered per plan year (Under Preventive Care) $25 co-pay for office visit Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Hearing Aid & Supplies NOTE: Payment of charges are capped to the maximum allowed amount. Contact your hearing aid provider or Anthem for details. | Subject to deductible
| Subject to deductible 70% reimbursement |
| Home Health Care Services 100 visit limit per plan year (Combined with Private Duty Nursing) | Subject to deductible 80% reimbursement | Paid as in-network |
| Hospice Services | Subject to deductible 100% reimbursement | Paid as in-network |
| Inpatient & Outpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) | Subject to deductible 80% reimbursement | Subject to deductible
|
| Mammograms Preventive | No deductible 100% reimbursement | No deductible 70% reimbursement |
| Mammograms Diagnostic | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Pre and postnatal physician services | $25 co-pay for first visit; afterwards 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Delivery: Vaginal & Cesarean | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Labs & Radiology | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Mental Health Inpatient and Residential Treatment (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
Outpatient Counseling
| First 6 visits of plan year with an EAP/AllOne Health or Anthem Network Provider No deductible After 6 visits | Non Anthem Network Provider Subject to deductible |
Occupational Therapy Inpatient | Subject to deductible
| Subject to deductible 70% reimbursement |
| Occupational Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) | No deductible $25 co-pay | Subject to deductible 70% reimbursement |
| Outpatient & Inpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) | Subject to deductible
| Subject to deductible
|
Physical Therapy Inpatient | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Physical Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Preventive Care | No deductible 100% reimbursement for eligible procedures | No deductible 70% reimbursement |
| Second Surgical Opinion | Subject to deductible 100% reimbursement | Paid as in-network |
| Skilled Nursing Facility (Pre-certification required) Case management available if applicable. | Limited to 60 days No deductible 80% reimbursement | Paid as in-network |
Speech Therapy Inpatient | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Speech Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Surgery (inpatient, outpatient, doctorās office & other) (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| TMJ | Subject to deductible 80% reimbursement | Paid as in-network |
| Transgender Health Care Services (Including gender reassignment surgery and coverage of medically necessary and preventive care procedures regardless of gender identity) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Transplants (Transplant program is available) | Subject to deductible 80% reimbursement No specific maximums | Subject to deductible Paid as in-network |
| Urgent Care Facility | $25 co-pay | Subject to deductible 70% reimbursement |
| Vision Screening Anthem Blue Cross & Blue Shield Preventive Benefits | Preventive Vision Screening No deductible 100% reimbursement | Preventive Vision Screening No deductible 70% reimbursement |
Substance Abuse (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Substance Abuse Outpatient Counseling (Pre-certification required) | First 6 visits of plan year with an EAP/AllOne Health or Anthem Network Provider No deductible 100% reimbursement After 6 visits No deductible $25 co-pay 80% reimbursement | Non Anthem Network Provider Subject to deductible 70% reimbursement |
2025-26 Faculty, Administrative, AFSCME 3200 & FOP Benefits Guide [PDF]
Effective July 1, 2025- June 30, 2026
2024-25 Faculty, Administrative, AFSCME 3200 & FOP Benefits Guide [PDF]
Effective July 1, 2024- June 30, 2025
AFSCME 1699
Review the Cost Sharing Summary for a detailed listing of deductibles, co-insurance, plan year maximums and office visit co-pays. Expand the PPO Medical Plan Coverage Chart (Alphabetical Listing) heading to view a listing of the in-network and out-of-network coverage for a variety of categories.
The Collective Bargaining Agreement will supersede the following information in case of discrepancies.
PPO Medical Plan and Prescription Cost Sharing Summary
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Deductible The member must pay all costs up to this amount before the plan begins to pay for covered services. Some specific services, such as preventive care, do not apply to the deductible. See the coverage chart for more details. In-network and Out-of-Network accrue separately. | $800/$1,600 Individual/ Family | $1,600/$3,200 Individual/ Family |
| Plan Co-Insurance A cost sharing feature in which the plan (Anthem Blue Cross Blue Shield) pays a fixed percentage of the cost of medical care. | 80% for most categories | 70% for most categories |
| Employee Co-Insurance A cost sharing feature in which the Member pays a fixed percentage of the cost of medical care. | 20% for most categories | 30% for most categories |
| Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) | No deductible $25 co-pay | Subject to deductible 70% reimbursement |
Plan Year Maximums
Out-of-pocket maximums accumulate separately; therefore, charges for out-of-network services cannot be applied to the in-network employee out-of-pocket maximum and vice versa
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Employee Co-Insurance Maximum Equal the total employees will pay for co-insurance during the plan year. | $2,700/$5,400 Individual/Family | $5,400/$10,800 Individual/Family |
| Employee Out-of-Pocket Maximum Equals the total employees will pay in deductibles and co-insurance during the plan year. | $3,500/$7,000 Individual/Family | $7,000/ $14,000 Individual/Family |
| Employee Office Visit Co-Pay Maximum Equals the total employees will pay for Office Visit co-pays during the plan year. | $2,325/$4,650 Individual/Family | Out of Network Co-Pay not applicable |
| Employee Prescription Co-Pay Maximum Equals the total employees will pay for Prescription co-pays during the plan year. | $2,000/$4,000 Individual/Family | Out of Network Co-Pay not applicable |
| Total Annual Out-of-Pocket Maximum | $7,850 / $15,650 | See Above |
Individual Lifetime Maximum Benefits, Unlimited
Prescription Drug Coverage
| Category | Retail Pharmacy | Mail Order Pharmacy |
|---|---|---|
| Generic Drug | $20 | $25 |
| Brand Name Formulary | $30 | $40 |
| Brand Name Non-Formulary | $40 | $55 |
Eligible Specialty Medications: 30% coinsurance or $0 copay if enrolled in PrudentRx Specialty Drug Program
PPO Medical Plan Coverage Chart (Alphabetical Listing)
| Category | In-Network (Tier 1) | Out-of-Network (Tier 2) |
|---|---|---|
| Ambulance (subject to medical necessity) | Subject to deductible 80% reimbursement | Paid as in-network |
| Child Wellness Visits Anthem Blue Cross and Blue Shield Standards | No deductible 100% reimbursement for eligible procedures | Subject to deductible 70% reimbursement |
| Chiropractic Services 12 visit limit per plan year | $25 co-pay | Subject to deductible 70% reimbursement |
| Durable Medical Equipment | Subject to deductible 80% reimbursement | Paid as in-network |
| Emergencies A medical emergency is defined by insurance company standards. May include a condition that if untreated could be life threatening or seriously impair bodily functions. | $75 co-pay The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit. | Paid as in-network |
| Gynecological Exams/PAP Smears Preventive and Diagnostic | $25 co-pay for office visit | No deductible 70% reimbursement |
| Hearing NOTE: Hearing medical conditions are covered the same as any other condition. | One routine hearing exam covered per plan year (Under Preventive Care) $25 co-pay for office visit Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Hearing Aid & Supplies NOTE: Payment of charges are capped to the maximum allowed amount. Contact your hearing aid provider or Anthem for details. | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Home Health Care Services 100 visit limit per plan year (Combined with Private Duty Nursing) | Subject to deductible 80% reimbursement | Paid as in-network |
| Hospice Services | Subject to deductible 100% reimbursement | Paid as in-network |
| Inpatient & Outpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Mammograms Preventive | No deductible 100% reimbursement | No deductible 70% reimbursement |
| Mammograms Diagnostic | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Pre and postnatal physician services | $25 co-pay for first visit; afterwards 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Delivery: Vaginal & Cesarean | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Maternity Labs & Radiology | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Mental Health Inpatient and Residential Treatment (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
Outpatient Counseling
| First 6 visits of plan year with an EAP/AllOne Health or Anthem Network Provider No deductible After 6 visits | Non Anthem Network Provider Subject to deductible |
Occupational Therapy Inpatient | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Occupational Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) | No deductible $25 co-pay | Subject to deductible 70% reimbursement |
| Outpatient & Inpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
Physical Therapy Inpatient | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Physical Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Preventive Care | No deductible 100% reimbursement for eligible procedures | No deductible 70% reimbursement |
| Second Surgical Opinion | Subject to deductible 100% reimbursement | Paid as in-network |
| Skilled Nursing Facility (Pre-certification required) Case management available if applicable. | Limited to 60 days No deductible 80% reimbursement | Paid as in-network |
Speech Therapy Inpatient | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Speech Therapy Outpatient | $25 co-pay | Subject to deductible 70% reimbursement |
| Surgery (inpatient, outpatient, doctorās office & other) (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| TMJ | Subject to deductible 80% reimbursement | Paid as in-network |
| Transgender Health Care Services (Including gender reassignment surgery and coverage of medically necessary and preventive care procedures regardless of gender identity) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Transplants (Transplant program is available) | Subject to deductible 80% reimbursement No specific maximums | Subject to deductible Paid as in-network |
| Urgent Care Facility | $25 co-pay | Subject to deductible 70% reimbursement |
| Vision Screening Anthem Blue Cross & Blue Shield Preventive Benefits | Preventive Vision Screening No deductible 100% reimbursement | Preventive Vision Screening No deductible 70% reimbursement |
Substance Abuse (Pre-certification required) | Subject to deductible 80% reimbursement | Subject to deductible 70% reimbursement |
| Substance Abuse Outpatient Counseling (Pre-certification required) | First 6 visits of plan year with an EAP/AllOne Health or Anthem Network Provider No deductible 100% reimbursement After 6 visits No deductible $25 co-pay 80% reimbursement | Non Anthem Network Provider Subject to deductible 70% reimbursement |
2025-26 AFSCME 1699 Benefits Guide [PDF]
Effective July 1, 2025- June 30, 2026
2024-25 AFSCME 1699 Benefits Guide [PDF]
Effective July 1, 2024- June 30, 2025
51ĀŅĀ×'s PPO medical plan is administered by Anthem Blue Cross/ Blue Shield.
The PPO plan is a "preferred provider organization." A PPO is a program in which a network of doctors, hospitals and other health care providers agree to provide medical services to plan enrollees at special, negotiated rates. Each health care provider in the network must meet and maintain strict quality requirements.
When you use network providers for your health care, you will have to pay a co-payment at the time of your service. Most services are covered at 80% after the deductible is met. You will still receive coverage when you see health care providers outside of the network, although you will receive a lower benefit level.
51ĀŅĀ× does not have any Pre-Existing Condition Limitations. (A pre-existing condition is a physical or mental health condition, disability, or illness that you have before you enrolled in a health plan).
NOTE: Payment for all covered health care services are based on the maximum allowed amount. For in-network providers and services, the maximum allowed amount is the rate agreed upon by Anthem and the provider of services and is normally less than the billed amount. For out-of-network providers and services, the maximum allowed amount is set by Anthem.