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Benefit Summary: Flexible Choice Plan

 

Flexible Choice Plan Summary for Active Employees and Dependents
Benefit Coverage
Calendar Year Deductible
PPO Providers $1,050 per person; $3,150 per family
Non-PPO Providers $2,100 per person; $6,300 per family
Note: Eligible expenses are cross applied to both the in-network and out-of-network deductibles.
Coinsurance
PPO Providers & all Emergency Care (Note: Emergency medical care received at a non-PPO hospital is paid at in-network coinsurance level.) Fund pays 80% of covered expenses after deductible. IHD will contact you if you have been admitted to a hospital to assist with coordinating your post-discharge care.
Non-PPO Providers Fund pays 60% of covered expenses after deductible
Calendar Year Out-of-Pocket Medical Maximum (Including the Deductible)
For non-Medicare retirees and dependents
PPO Providers $2,000 per person; $4,000 per family
Non-PPO Providers Unlimited
For Active Members
PPO Providers $5,000 per person or family
Non-PPO Providers Unlimited
Calendar Year Out-of-Pocket Prescription Drug Maximum (Including the Deductible)
For non-Medicare retirees and dependents
PPO & Non-PPO Providers $4,600 per person; $9,200 per family
For Active Members
PPO & Non-PPO Providers $1,600 per person; $8,200 per family
Note: Any amount you pay toward eligible health care services and supplies you receive in-network and/or out-of-network will be cross applied to and accumulate toward your out-of-pocket maximum.
Lifetime Maximum for All Covered Expenses for Active Employees and Dependents (Excluding Substance Abuse Treatment and Home Nursing Care) Unlimited
Adult Well Care*
Annual routine physical exam (including associated laboratory and radiology services) and adult immunizations (includes office visit expense) Fund pays 100% of covered expenses. Deductible does not apply.
Diagnostic sigmoidoscopy Fund pays 100% of covered expenses. Deductible does not apply. Once per 3 calendar years beginning at age 50.
Diagnostic colonoscopy (provided in accordance with American Cancer Society guidelines) Fund pays 100% of covered expenses. Deductible does not apply.
Additional covered preventive services for adults are listed in the June 1 Plan Changes Notice.
Adult Female Care*
Annual gynecological exam and pap smear (including office visit expense) Fund pays 100% of covered expenses. Deductible does not apply.
Mammography screening (1 baseline: age 35 to 40; annually: age 40+) Fund pays 100% of covered expenses. Deductible does not apply.
HPV testing Fund pays 100% of covered expenses. Deductible does not apply.
Bone density testing for osteoporosis $250; balance covered at 80%. Deductible does not apply.
Adult Male Well Care*
Annual prostate exam (including PSA test) Fund pays 100% of covered expenses. Deductible does not apply.
Child Well Care*
Routine new baby care for children less than age 2 (for hospital and office visits, laboratory, and radiology services) Fund pays 100% of covered expenses. Deductible does not apply.
Routine physical exam for children age 2 through 18 (for office visits, laboratory, and radiology services) Fund pays 100% of covered expenses. Deductible does not apply
Necessary immunizations Fund pays 100% of covered expenses. Deductible does not apply.
HPV vaccine for girls and boys between the ages of 9 and 26 Fund pays 100% of covered expenses. Deductible does not apply.
Also see the Advisory Committee on Immunization Practices page on the Centers for Disease Control and Prevention website for additional immunization and vaccine information.
Chiropractic Care
PPO Providers Fund pays 80% of covered expenses after deductible
Non-PPO Providers Fund pays 60% of covered expenses after deductible
Calendar Year Maximum $500 per calendar year per person
Organ Transplant Benefit
Blue Distinction Providers Fund pays 100% of covered expenses
PPO Providers Fund pays 80% of covered expenses after deductible
Non-PPO Providers Not covered
Behavioral Health Treatment(pre-certification required)**
Calendar Year Maximum Unlimited
Lifetime Maximum for Substance Abuse Treatment Unlimited
Mental Health/Substance Abuse Outpatient Treatment PPO Providers: Fund pays 80% of covered expenses after deductible. Non-PPO Providers: Fund pays 60% of covered expenses after deductible.
Mental Health/Substance Abuse Inpatient Treatment If pre-certified: Covered same as any other illness.

If not pre-certified: A $250 per confinement penalty will apply.

Outpatient Laboratory Program
Laboratory testing at any in-network facility (Lab One or Anthem Blue Cross Blue Shield PPO providers) Fund pays 100% of covered expenses. Deductible does not apply.
Laboratory testing at a non-PPO Provider Fund pays 60% of covered expenses after the deductible.
Member Assistance Program, provided by ComPsych
Member Assistance Program (MAP) Visits 1-5: Fund pays 100%; deductible does not apply. Visits 6 and up: The outpatient mental health/substance abuse benefit is paid.

*You must use PPO providers when receiving preventive, well-care services. The calendar year deductible does not apply.

**Either you or your provider must call ComPsych at 1-877-627-4239 to precertify inpatient hospital treatment for mental health and substance abuse. If you do not, you will be charged a $250 penalty fee. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care. Failure to make contact within seventy-two (72) hours of an emergency admission will result in application of the $250 penalty fee.