Benefit Summary: Flexible Choice Plan
| 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. |
| Non-PPO Providers | Fund pays 60% of covered expenses after deductible |
| Calendar Year Medical Out-of-Pocket 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 Prescription Drug Out-of-Pocket Maximum | |
| 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 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 | Fund pays 100% of covered expenses. 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 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 | If pre-certified: Covered same as any other illness (limited to 60 days per calendar year; combined in- and out-of-network) |
| Mental Health/Substance Abuse Inpatient Treatment | Covered same as any other illness. |
| Outpatient Laboratory Program | |
| Laboratory testing at any in-network facility (Lab One or Highmark 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 Lyra Health | |
| Member Assistance Program (MAP) | Visits 1-8: Fund pays 100%; deductible does not apply. Visits 9 and up: The outpatient mental health/substance abuse benefit is paid. |
*Pre-certification through American Health Holding is required for hospitalization, skilled nursing, surgery, or inpatient 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.
**You must use PPO providers when receiving preventive, well-care services. The calendar year deductible does not apply.
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