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)
(Tier 1)
(Tier 2)
(subject to medical necessity)
80% reimbursement
Anthem Blue Cross and Blue Shield Standards
70% reimbursement
12 visit limit per plan year
70% reimbursement
80% reimbursement
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.
The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit.
Preventive and Diagnostic
70% reimbursement
NOTE: Hearing medical conditions are covered the same as any other condition.
$25 co-pay for office visit
Subject to deductible
80% reimbursement
70% reimbursement
NOTE: Payment of charges are capped to the maximum allowed amount. Contact your hearing aid provider or Anthem for details.
Subject to deductible80% reimbursement
70% reimbursement
100 visit limit per plan year (Combined with Private Duty Nursing)
80% reimbursement
100% reimbursement
(non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.)
80% reimbursement
Subject to deductible 70% reimbursement
Preventive
100% reimbursement
70% reimbursement
Diagnostic
80% reimbursement
70% reimbursement
Pre and postnatal physician services
70% reimbursement
Delivery: Vaginal & Cesarean
80% reimbursement
70% reimbursement
Labs & Radiology
80% reimbursement
70% reimbursement
Inpatient and Residential Treatment
(Pre-certification required)
80% reimbursement
70% reimbursement
Outpatient CounselingPre-certification required for:
- Inpatient Care
- Partial Hospitalization
- Residential Care
- Transcranial Magnetic Stimulation (TMS)
First 6 visits of plan yearwith an EAP/AllOne Health or Anthem Network Provider
No deductible100% reimbursement
After 6 visits
No deductible $25 co-pay
100% reimbursement
Non Anthem Network Provider
Subject to deductible70% reimbursement
Occupational Therapy40 visit limit per plan year
Inpatient
Subject to deductible80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
(Primary Care, Specialty Care, Physical Therapy, etc.)
$25 co-pay
70% reimbursement
(non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.)
Subject to deductible80% reimbursement
Subject to deductible 70% reimbursement
Physical Therapy40 visit limit per plan year
Inpatient
80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
Anthem Blue Cross and Blue Shield Standards
100% reimbursement for eligible procedures
70% reimbursement
100% reimbursement
(Pre-certification required)
Case management available if applicable.
No deductible
80% reimbursement
Speech Therapy30 visit limit per plan year
Inpatient
80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
(inpatient, outpatient, doctor’s office & other)
(Pre-certification required)
80% reimbursement
70% reimbursement
80% reimbursement
(Including gender reassignment surgery and coverage of medically necessary and preventive care procedures regardless of gender identity)
80% reimbursement
70% reimbursement
(Transplant program is available)
80% reimbursement
No specific maximums
Paid as in-network
70% reimbursement
Anthem Blue Cross & Blue Shield Preventive Benefits
No deductible
100% reimbursement
No deductible
70% reimbursement
Substance AbuseInpatient and Residential Treatment
(Pre-certification required)
80% reimbursement
70% reimbursement
Outpatient Counseling
(Pre-certification required)
EAP/AllOne Health or Anthem Network Provider
No deductible
100% reimbursement
After 6 visits
No deductible
$25 co-pay
80% reimbursement
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)
(Tier 1)
(Tier 2)
(subject to medical necessity)
80% reimbursement
Anthem Blue Cross and Blue Shield Standards
70% reimbursement
12 visit limit per plan year
70% reimbursement
80% reimbursement
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.
The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit.
Preventive and Diagnostic
70% reimbursement
NOTE: Hearing medical conditions are covered the same as any other condition.
$25 co-pay for office visit
Subject to deductible
80% reimbursement
70% reimbursement
NOTE: Payment of charges are capped to the maximum allowed amount. Contact your hearing aid provider or Anthem for details.
80% reimbursement
70% reimbursement
100 visit limit per plan year (Combined with Private Duty Nursing)
80% reimbursement
100% reimbursement
(non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.)
80% reimbursement
70% reimbursement
Preventive
100% reimbursement
70% reimbursement
Diagnostic
80% reimbursement
70% reimbursement
Pre and postnatal physician services
70% reimbursement
Delivery: Vaginal & Cesarean
80% reimbursement
70% reimbursement
Labs & Radiology
80% reimbursement
70% reimbursement
Inpatient and Residential Treatment
(Pre-certification required)
80% reimbursement
70% reimbursement
Outpatient CounselingPre-certification required for:
- Inpatient Care
- Partial Hospitalization
- Residential Care
- Transcranial Magnetic Stimulation (TMS)
First 6 visits of plan yearwith an EAP/AllOne Health or Anthem Network Provider
No deductible100% reimbursement
After 6 visits
No deductible $25 co-pay
100% reimbursement
Non Anthem Network Provider
Subject to deductible70% reimbursement
Occupational Therapy40 visit limit per plan year
Inpatient
80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
(Primary Care, Specialty Care, Physical Therapy, etc.)
$25 co-pay
70% reimbursement
(non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.)
80% reimbursement
70% reimbursement
Physical Therapy40 visit limit per plan year
Inpatient
80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
Anthem Blue Cross and Blue Shield Standards
100% reimbursement for eligible procedures
70% reimbursement
100% reimbursement
(Pre-certification required)
Case management available if applicable.
No deductible
80% reimbursement
Speech Therapy30 visit limit per plan year
Inpatient
80% reimbursement
70% reimbursement
Outpatient
70% reimbursement
(inpatient, outpatient, doctor’s office & other)
(Pre-certification required)
80% reimbursement
70% reimbursement
80% reimbursement
(Including gender reassignment surgery and coverage of medically necessary and preventive care procedures regardless of gender identity)
80% reimbursement
70% reimbursement
(Transplant program is available)
80% reimbursement
No specific maximums
Paid as in-network
70% reimbursement
Anthem Blue Cross & Blue Shield Preventive Benefits
No deductible
100% reimbursement
No deductible
70% reimbursement
Substance AbuseInpatient and Residential Treatment
(Pre-certification required)
80% reimbursement
70% reimbursement
Outpatient Counseling
(Pre-certification required)
EAP/AllOne Health or Anthem Network Provider
No deductible
100% reimbursement
After 6 visits
No deductible
$25 co-pay
80% reimbursement
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
Ohio University'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.
Ohio University 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.