Bowdoin College PPO Health Plan

stethThe Bowdoin College PPO Health Plan is a Preferred Provider Organization (PPO) plan provided through Anthem. The PPO health plan covers many medical expenses such as doctor visits, lab tests, medications, medical treatments and mental health benefits. 

How much does it cost?

The monthly costs made (via payroll deduction) on a pre-tax basis are as follows (effective 1-1-17): PPO Health Plan Costs.

What does it cover?

The Bowdoin College PPO Health Plan is a very rich plan that includes coverage for:

  • Primary Care Physician Office Visits
  • Specialty Physician Office Visits
  • Preventive Care (such as routine physicals, health screenings and well child visits)
  • Hospital Visits
  • Mental Health
  • Routine Eye Exams (limited – see the EyeMed Vision Plan for more robust coverage)
  • Medical Tests (such as X-ray and lab services)
  • Prescription Medications

Bowdoin College Benefit Summary Chart for 2017

Helpful terms and definitions

Before you get started, there are a few terms you will want to understand.

Preferred In-Network –  Bowdoin College works with a group of health care providers known as “Preferred In-Network” providers with additional cost savings. 

In-Network – Anthem has contracts with many providers in Maine and across the United States, known as “In-Network” providers.   Anthem has special rates with these providers, so if you go to an In-Network doctor or hospital you will be able to pay less out of pocket.  You can see who is on the list of network providers at Anthem’s website.

Out-of-Network – With a PPO plan, you do not have to go to an In-Network or Preferred-In-Network provider if you do not wish to.  However, because Out-of-Network providers do not have a contract with Anthem, it will cost more for both you and the College.  It is important to understand that if you receive services from an Out-of-Network doctor or hospital, the health plan will pay benefits based on the “maximum allowances.”  This means that any amount that an Out-of-Network doctor or hospital charges that is above the maximum allowance will be billed to you directly before the Out-of-Network benefits begin to pay.  This can mean significantly higher out-of-pocket costs to you.  For example, if an Out-of-Network doctor charges $175 for an office visit and the maximum allowance is $100, you will have to pay $75 before the deductible and coinsurance are applied.

Deductible - The deductible is the amount of money you need to pay before the insurance pays.  The Preferred In-Network deductible on the health plan is $500 for an individual or $1,000 for a family and the In-Network deductible is $750 for an individual and $1,500 for a family.  For many of the services covered by the health plan, you will need to meet your deductible before the benefit applies.

Copayment (Copay) - For some services and for prescription drugs, you will have to pay a copay.  A copay is the amount of money you pay for a service, separate from your deductible.  Your copay is usually a small percentage of the overall cost, especially if you use In-Network providers.   For example, if you go to an In-Network primary care doctor, you pay $20 and the insurance company pays the rest (which typically ranges from $100-$170 in Southern Maine).  Copays are a set dollar amount.

Coinsurance – Coinsurance is the percent of the cost of your care that you need to pay after you have paid your deductible.  For Preferred In-Network services, the co-insurance is 10%, for the In-Network services it is 30% and for Out-of-Network services it is 50%.

Out-of-Pocket Maximum – The “Out-of-Pocket” maximum is the total amount of money (deductible plus coinsurance plus medical co-payments) that you will pay for medical services in a benefit year (calendar year).   Benefits are paid at 100% for the remainder of the calendar year once you have reached your out-of-pocket maximum.  There is a separate out-of-pocket maximum for prescription drug copayments:  $3,150/individual and $6,300/family.  Out-of-Network charges that are in excess of the maximum allowance do not count toward your out-of-pocket maximum.   The preferred in-network out of-pocket calendar year limit in 2017 is $3,000 per individual/$6,000 per family. The in-network out-of-pocket calendar year limit in 2017 is $4,000 per individual/$8,000 per family.

 

How do I use the plan?

Below you can find basic explanations of commonly used services and tips for using the health plan.

Doctor Visits – The plan has different co-pays for primary care (your personal or family doctor) or specialist visits and for doctors that are In-Network.   Out-of-Network office visits and other services are paid at 50% after the deductible and coverage is subject to the maximum allowances for the plan.  For In-Network primary care office visits, the co-pay is only $20 and for In-Network specialists it is $50 per visit.  You do not need to pay a deductible or coinsurance on regular In-Network office visits (such as going to your primary care doctor when you are sick).

Laboratory Tests and X-rays – Lab tests and x-rays are subject to your deductible and coinsurance.

Prescription Medications – Bowdoin College has a tiered drug plan, which means your co-pay will depend on the type of drug your doctor prescribes. 

  • Tier 1 - $10 copay for a 30-day supply (includes generic drugs and some brand name medications used to manage chronic health conditions)
  • Tier 2 - $40 copay for a 30-day supply (includes brand name drugs without a generic equivalent)
  • Tier 3 - $70 copay for a 30-day supply (may include more costly medications or medications very recently approved by the Food and Drug Administration)

Non-Conventional Therapy - Acupuncture

  • Acupuncture:  Benefits are provided for covered services received from a licensed provider in calendar year 2017.  The plan pays 50% after the deductible and there is a 20 visit limit per calendar year.  There are no acupuncture providers in Anthem’s network.  For this reason, you must pay the provider upfront and submit an Anthem claim form along with the receipt from the provider for reimbursement.  Please be certain that the receipt from the provider lists his/her name, address, date of service, amount charged, procedure code and lists the medical diagnosis requiring treatment 

How does our prescription plan work?

Bowdoin College has a tiered drug plan, which means your co-pay will depend on the type of drug your doctor prescribes. 

  • Tier 1 - $10 copay for a 30-day supply (includes generic drugs and some brand name medications used to manage chronic health conditions)
  • Tier 2 - $40 copay for a 30-day supply (includes brand name drugs without a generic equivalent)
  • Tier 3 - $70 copay for a 30-day supply (may include more costly medications or medications very recently approved by the Food and Drug Administration)

You can easily review a list of what drugs are included in the Anthem prescription drug list or formulary.   You do not need to meet your deductible for prescriptions – only the co-pay applies.  Some prescription medicines may need to be reviewed to make sure they are appropriate, safe, and affordable for you and are covered by our plan.  Read more about Anthem's Step Therapy and Prior Authorization.

TIP:  If you are taking a drug that you can buy through Anthem’s Mail Order Pharmacy Program, you can save money and Bowdoin saves money.  Retail pharmacies also honor the mail order 90-day supply discount as well.  A 90-day supply of a Tier 1 drug is $20, Tier 2 is $100 and Tier 3 is $175.

Preventive Care Services

Preventive Care – Preventive care services are offered at no cost.  Routine physicals, mammograms, Pap smears, and colonoscopies are covered at 100% when they are done as part of a recommended screening schedule.  The recommended screenings and immunizations can change depending on your gender, age, and family health history.   

Provisions of Health Care Reform provide enhancements to women’s preventive services covered at 100% including:  Well Women exams, prescription contraceptives (generics and brand name drugs with no generic equivalent), sterilization procedures and patient education/counseling for women, breastfeeding support, supplies and counseling, etc.   Services must be obtained from an in-network provider for 100% coverage.

Be sure to ask your doctor if any preventive screenings are recommended for you.

How do I contact Anthem or find claim forms?

Anthem
P.O. Box 533
North Haven, CT  06473
1-800-527-7706
www.anthem.com/bowdoincollege

You can also download a medical claim form or prescription drug claim form.

Bowdoin College PPO Health Plan Benefit Summary Chart and Plan Documents