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Tier 1 - Typically Generic 30 day supply (retail pharmacy). 90 day supply (home delivery). $10 copay per prescription, deductible does not apply (retail) and $20 copay per prescription, deductible does not apply (home delivery) 50% coinsurance deductible does not apply (retail) and Not covered (home delivery) Tier 2 – Typically Preferred Brand. Tier 2 – Typically Preferred/Formulary Brand $30 copay/ prescription (retail only) and $60 copay/prescription (mail order only) 50% coinsurance If the member selects a brand drug when a generic equivalent is available the member is responsible for the generic copay plus the cost difference between the generic and brand equivalent, even if. This Anthem HealthKeepers plan does offer additional coverage through the gap. H3447-021 Formulary or Drug Coverage. Anthem MediBlue Plus (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Prescription Drug Copays for 2021 at Level Two; Level 2: 30-Day Supply (Retail) Yearly Cost 30-Day Supply (Retail) 90-day Supply (Mail Order) Yearly Cost 90-Day Supply (Mail Order) Tier 1: $15 copay: $180.00: N/A: N/A: Tier 2: $60 copay: $720.00: N/A: N/A: Tier 3: $80 copay: $960.00: N/A: N/A: Tier 4: 25% of our allowance ($250 maximum per prescription) — 90-day supply is not available.

The Anthem Plans are available for all U.S. employees.

Anthem Blue Cross Exclusive	Anthem Blue Cross Preferred		Anthem Blue Cross HDHP
*In-Network Only* Anthem PPO Network	In-Network Anthem PPO Network	Out-of-Network	In-Network Anthem PPO Network	Out-of-Network
Calendar Year Deductible	$100/Individual $300/Family	$300/Individual $900/Family		$2,000/Individual $2,800/Individual up to $4,000/Family
% Co-Insurance	10%	20%	35%	10%	30%
Out-of-Pocket Maximum	$2,000/Individual $6,000/Family	$2,000/Individual $6,000/Family	$4,000/Individual $12,000/Family	$5,000/Individual $10,000/Family	$5,000/Individual $10,000/Family
Doctor's Office Visits	$20 copay*	$25 copay*	35%	10%	30%
Telemedicine Visit	No charge with LiveHealth Online	No charge with LiveHealth Online	NA	$59; 0% after deductible** LiveHealth Online	NA
Specialist Office Visits	$30 copay*	$35 copay*	35%	10%	30%
Urgent Care	$20 copay*	$25 copay*	35%	10%	30%
Emergency Room Services	10% after $100 copay (waived if admitted)	20%* after $100 copay (waved if admitted)		10%

* Deductible does not apply
**$59 fee waived during the pandemic
NOTE: Out-of-network coverage based on Anthem Blue Cross’s maximum allowed amount.
View a comparison of all the Marvell medical plans on the 2021 At-a-Glance.

Prescription Drugs + Mail Order

When you enroll in an Anthem medical plan, you are automatically enrolled in a four-tier prescription drug plan that provides you with multiple options to save money.

Exclusive & Preferred: A separate $2,000/Individual Out-of-Pocket Maximum ($6,000/Family) applies for prescription drugs.

High Deductible Health Plan (HDHP): The Out-of-Pocket maximum is combined with the Medical Out-of-Pocket maximum. You will pay the full retail price for prescriptions until you meet the Deductible. After meeting the Deductible then the prescription copay will apply.

Description	In-Network Pharmacy
Tier 1	Lowest Member Cost Share: These drugs offer the greatest value compared to others that treat the same conditions.	$10 copay
Tier 2	Medium Member Cost Share: These may be preferred brand drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.	$30 copay
Tier 3	Higher Member Cost Share: These generally include non-preferred brand and generic drugs. They may cost more than drugs placed on lower tiers that are used to treat the same conditions.	$50 copay
Tier 4	Highest Member Cost Share: Many drugs on this tier are specialty drugs used to treat complex, chronic conditions and may require special handling and/or management.	$100 copay

Note: If you use an out-of-network pharmacy, you will pay the applicable copay + 50% of covered expenses.

Prescription Drug Mail Orders: Receive a 90-day supply for 2x the copay amount. Learn how to enroll here.

Anthem Prescription Drug List

To transfer prescriptions to Anthem:

Prescriptions you pick up at the pharmacy: Provide the pharmacy with your Anthem ID card to update your insurance coverage.
Mail Order Prescriptions: request a new script from your physician and submit a request for a new mail-order prescription through Anthem's pharmacy benefits manager, IngenioRX, by either:
- Logging into your account at anthem.com/ca, choose Pharmacy, and on your personal pharmacy page select View Your Prescriptions under Switch to a 90-Day Supply. For the drugs you want to switch to home delivery, choose Switch to a 90-day Supply and then Select Prescriber; you can also add your shipping address, options, and payment methods on this page
- Completing and sending in the Home Delivery Order Form.

Telemedicine Appointments with LiveHealthOnline.com

Anthem members have access to free* online doctor visits or psychologist visits 24/7 through LiveHealthOnline.com. Download the app and sign in (linking your Anthem member ID) so you're ready the next time you need medical attention:

Services include:

Medical: Get advice, a treatment plan, and prescriptions (if needed)
Kids: Speak immediately with a pediatrician and receive expert advice and treatment
Psychology: Talk with a therapist from the privacy of your home in 4 days or less
Psychiatry: See a psychiatrist and discuss possible medication management needs
Allergy: Consult with a doctor who knows the latest allergy treatment trends

*Members enrolled in the HDHP pay $59/visit until their annual deductible has been met but this has been waived during the pandemic.

In-Network Provider Search for the Anthem Network

If you haven't enrolled in Anthem coverage yet and want to search for in-network doctors, please use the below instructions.

Go to: https://www.anthem.com/ca/health-insurance/providerreimagine-directory/searchcriteria?brand=ABC
Select the 'Guest' tile. Do not click the 'change state' button. It will list California but you still be able to search providers outside of California.
When prompted, search by plan and select the following:
- What type of care are you searching for? Medical
- What state do you want to search in? Select state
- What type of plan do you want to search with? Medical (Employer-Sponsored)
- Select a plan/network: National PPO (BlueCard PPO)

Anthem Tier 2 Copay