The Plan’s three provider tiers of coverage

The Plan lets you choose any provider, but benefit coverage depends on your provider choice.

Tier 1 – providers from Keck Medicine of USC

  • You pay a $15 copay for office visits
  • No charge for most preventive or well child care visits
  • Annual medical deductible – $100 individual/$300 family (does not apply to services that have a flat dollar copay, like office visits)
  • Plan pays 100% of hospital room/board charges for maternity delivery at USC Verdugo Hills Hospital (the only Tier 1 provider for hospital maternity delivery)
  • Annual medical out of pocket maximum – $1000 individual/$3000 family (three or more people in the same family)

Tier 2 – Anthem Blue Cross Prudent Buyer/BlueCard providers

  • Large network of physicians and hospitals across the U.S. and worldwide (international)
  • You pay a $25 copay for office visits
  • Tier 1 benefit coverage applies to covered persons up to age 26 even when using Tier 2 providers
  • Annual medical deductible – $250 individual/$750 family (does not apply to services that have a flat dollar copay, like office visits)
  • Preventive/well child care coverage at 100%
  • LiveHealth Online – primary care physician visit¬†available online
  • Maternity delivery (hospital room/board charges) at Good Samaritan Hospital¬†(a Tier 2 provider) is covered at a $100 copay (instead of $300 copay) when delivery is performed by a USC Care Medical Group obstetrician
  • Tier 1 benefit coverage applies to covered persons up to age 26 even when using Tier 2 provider
  • Annual medical out of pocket maximum – $2500 individual/$7500 family (three or more people in the same family)

Tier 3 – all other providers (non-contracted)

  • For office visits, preventive care and well child services, Plan pays 50% of “usual, customary and reasonable” charges; you pay remainder
  • Annual medical deductible – $500 individual / $1500 family (does not apply to services that have a flat dollar copay, like office visits)
  • Annual medical out of pocket maximum – $10,000 individual/$30,000 family (three or more people in the same family)