Medical

Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.

AVMC offers three medical plan options:

  1. PPO Plan (Anthem Blue Cross Prudent Buyer PPO network)
  2. EPO Plan (Anthem Blue Cross Prudent Buyer PPO network)
  3. Kaiser Permanente HMO Plan

Review your Benefits Guide for more information regarding your plan options.

Each plan has different:

  • Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
  • Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
  • Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
  • Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.

Prescription Drugs

If you enroll in either the PPO/EPO, you are automatically enrolled in the prescription drug plan administered by RxBenefits/Express Scripts Inc. (ESI). Kaiser members will receive prescriptions from Kaiser facilities.

PPO/EPO

  • You will not be issued a separate prescription drug card; the prescription drug information is combined with your medical ID card.
  • To access a complete listing of pharmacies near you, log onto express-scripts.com.
  • No claim forms to fill out.
  • Mail order program for maintenance medications is both convenient and cost-effective. You receive a three-month supply for only two months copays.
  • To ensure maximum quality, efficacy, and affordability, step therapy and prior authorization for certain drugs may be required.
  • Customer service can be reached at 800-334-8134.

Kaiser HMO

  • Prescription drug information is printed on your ID card.
  • To access a complete listing of pharmacies near you, log onto kaiserpermanente.org.
  • You can obtain a 100-day supply through the mail order.
Plan Documents
Plan Contacts

Anthem PPO

Benefit Highlights
AVMC

Deductible (Individual/Family)
$250/$500

Out-of-Pocket Max (Individual/Individual Within a Family/Family)
$1,000/$2,000/$3,000

Primary Care Visit
N/A

Specialist Visit
N/A

Urgent Care
N/A

Emergency Room
$100 copay + 20% after deductible

Retail Rx (Up to 30-Day Supply)

Generic
$10 copay

Preferred Brand
$25 copay

Non-Preferred Brand
$40 copay

Specialty
$25 copay

Mail-Order Rx (Up to 90-Day Supply)

Generic
$20 copay

Preferred Brand
$50 copay

Non-Preferred Brand
$80 copay

Specialty
$50 copay 

Out-of-Network

Deductible (Individual/Family)
$1,200/$2,400

Out-of-Pocket Max (Individual/Individual Within a Family/Family)
$6,000 /$16,000

Primary Care Visit
50% after deductible

Specialist Visit
50% after deductible

Urgent Care
50% after deductible

Emergency Room
$100 copay + 20% after deductible

Retail Rx (Up to 30-Day Supply)

Generic
$10 copay + 50%

Preferred Brand
$25 copay + 50%

Non-Preferred Brand
$40 copay + 50%

Specialty
$25 copay + 50%

Mail-Order Rx (Up to 90-Day Supply)

Generic
Not covered

Preferred Brand
Not covered

Non-Preferred Brand
Not covered

Specialty
Not covered

Prudent Buyer

Deductible (Individual/Family)
$600/$1,200

Out-of-Pocket Max (Individual/Individual Within a Family/Family)
$3,000/$8,000

Primary Care Visit
$20 copay

Specialist Visit
$30 copay

Urgent Care
20% after deductible

Emergency Room
$100 copay + 20% after deductible

Retail Rx (Up to 30-Day Supply)

Generic
$10 copay

Preferred Brand
$25 copay

Non-Preferred Brand
$40 copay

Specialty
$25 copay

Mail-Order Rx (Up to 90-Day Supply)

Generic
$20 copay

Preferred Brand
$50 copay

Non-Preferred Brand
$80 copay

Specialty
$50 copay

Click here to learn more about the Active&Fit program.

Plan Cost – SEIU Bargaining Unit Employees

Employee

Employee Only: $81.31
Employee + 1 Dependent: $175.86
Employee + Family: $234.69

Employer

Employee Only: $460.79
Employee + 1 Dependent: $996.55
Employee + Family: $1,329.90

Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees

Employee

Employee Only: $108.42
Employee + 1 Dependent: $234.49
Employee + Family: $312.91

Employer

Employee Only: $433.68
Employee + 1 Dependent: $937.93
Employee + Family: $1,251.67

Anthem EPO

Benefit Highlights
AVMC

Deductible (Individual/Family)
None

Out-of-Pocket Max (Individual/Individual Within a Family/Family)
$1,000/$2,000/$3,000

Primary Care Visit
N/A

Specialist Visit
N/A

Urgent Care
N/A

Emergency Room
$100 copay

Retail Rx (Up to 30-Day Supply)

Generic
$10 copay

Preferred Brand
$25 copay

Non-Preferred Brand
$40 copay

Specialty
$25 copay

Mail-Order Rx (Up to 90-Day Supply)

Generic
$20

Preferred Brand
$50

Non-Preferred Brand
$80

Specialty
$50

In-Network

Deductible (Individual/Family)
$500/$1,000

Out-of-Pocket Max (Individual/Individual Within a Family/Family)
$3,000/$5,000/$8,000

Primary Care Visit
$20 copay

Specialist Visit
$30 copay

Urgent Care
$20 copay

Emergency Room
$100 copay

Retail Rx (Up to 30-Day Supply)

Generic
$10 copay + 50%

Preferred Brand
$25 copay + 50%

Non-Preferred Brand
$40 copay + 50%

Specialty
$25 copay + 50%

Mail-Order Rx (Up to 90-Day Supply)

Generic
Not covered

Preferred Brand
Not covered

Non-Preferred Brand
Not covered

Specialty
Not covered

Click here to learn more about the Active&Fit program.

Plan Cost – SEIU Bargaining Unit Employees

Employee

Employee Only: $44.17
Employee + 1 Dependent: $97.17
Employee + Family: $132.48

Employer

Employee Only: $313.81
Employee + 1 Dependent: $690.99
Employee + Family: $948.30

Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees

Employee

Employee Only: $58.90
Employee + 1 Dependent: $129.57
Employee + Family: $176.64

Employer

Employee Only: $299.09
Employee + 1 Dependent: $658.59
Employee + Family: $904.14

Kaiser HMO

Benefit Highlights
In-Network

Deductible (Individual/Family)
None

Out-of-Pocket Max (Individual/Family)
$3,500 /$7,000

Primary Care Visit
$30 copay

Specialist Visit
$50 copay

Urgent Care
$30 copay

Emergency Room
$350 copay

Retail Rx (Up to 30-Day Supply)

Generic
$15 copay

Brand Name
$35 copay

Specialty
30% up to $250 copay

Mail-Order Rx (Up to 90-Day Supply)

Generic
$30 copay

Brand Name
$70 copay

Plan Cost – SEIU Bargaining Unit Employees

Employee

Employee Only: $49.08
Employee + 1 Dependent: $107.96
Employee + Family: $147.20

Employer

Employee Only: $255.28
Employee + 1 Dependent: $561.63
Employee + Family: $765.88

Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees

Employee

Employee Only: $65.44
Employee + 1 Dependent: $143.96
Employee + Family: $196.27

Employer

Employee Only: $238.92
Employee + 1 Dependent: $525.63
Employee + Family: $716.81

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