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Benefit Summary: Greenbrier Medical Plan

 

For Active Members and Dependents

Greenbrier Medical Plan Benefit Summary for Active Members and Dependents
Benefit Coverage
Calendar Year Deductible
PPO Providers $650 employee only;
$1,300 employee + one;
$1,500 family
Non-PPO Providers $650 employee only;
$1,300 employee + one;
$1,500 family
Greenbrier Care None
Note: Eligible expenses are cross applied to both the in-network and out-of-network deductibles.
Copay and Coinsurance*
PPO Providers Office visit $40; otherwise, Fund pays 80% of covered expenses after deductible.
Non-PPO Providers Office visits and other services, Fund pays 60% of covered expenses after deductible.
Greenbrier Care Office visit $10; otherwise, Fund pays 100% of covered expenses.
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 a separate $100 deductible.
IHD will contact you if you have been admitted to a hospital to assist with coordinating your post-discharge care.
Calendar Year Medical Out-of-Pocket Maximum (Including the Deductible)
PPO Providers $1,800 employee only;
$3,600 employee + one;
$5,400 family
Non-PPO Providers Unlimited
Greenbrier Care Not Applicable
Medical Plan copays and coinsurance count toward meeting the out-of-pocket maximum. Note: There is a separate prescription drug out-of-pocket maximum.
Separate, Calendar Year Prescription Drug Out-of-Pocket Maximum
Sav-Rx Network Pharmacy $1,800 employee only;
$3,600 employee + one;
$5,400 family
Lifetime Maximum for All Covered Expenses (Excluding Home Nursing Care) Unlimited
Adult Well Care (Greenbrier Care or In-Network)*
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  Plan Changes Notice.
Adult Female Care (Greenbrier Care or In-Network)*
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 (Greenbrier Care or In-Network)*
Annual prostate exam (including PSA test) Fund pays 100% of covered expenses. Deductible does not apply.
Child Well Care (Greenbrier Care or In-Network)*
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.

(Well baby care is not available at Greenbrier Care.)

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.
*Note: You must use PPO providers when receiving preventive, well-care services. If you go Out-of-Network, the deductible and coinsurance apply.
Chiropractic Care
Greenbrier Care Not available.
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 person.
Organ Transplant Benefit
Greenbrier Care Not available.
Blue Distinction Providers Fund pays 100% of covered expenses.
PPO Providers Fund pays 80% of covered expenses after deductible.
Non-PPO Providers Fund pays 60% of covered expenses after deductible.
Transportation and Lodging Allowance $10,000
Behavioral Health Treatment(pre-certification required)**
Lifetime Maximum for Substance Abuse Treatment Unlimited
Mental Health/Substance Abuse Outpatient Treatment Greenbrier Care: Not available. 

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 Greenbrier Care: Not available. 

Covered same as any other illness.

Outpatient Laboratory Program
Laboratory testing at Greenbrier Care Fund pays 100% of covered expenses. Deductible does not apply.
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.

*Pre-certification through American Health is required for hospitalization, skilled nursing or surgery.

**Either you or your provider must call ComPsych at 1-877-627-4239 to pre-certify inpatient hospital treatment for mental health and substance abuse. 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.