Member Benefits
Benefit Summary: Comprehensive Major Medical Plan
| Benefit | Coverage | |
|---|---|---|
| Calendar Year Deductible | ||
| PPO Providers | $350 per person; $1,050 per family | |
| Non-PPO Providers | $700 per person; $2,100 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 Out-of-Pocket Maximum (Including the Deductible) | ||
| For non-Medicare retirees and dependents | ||
| PPO Providers | $2,000 per person | |
| Non-PPO Providers | $4,000 per person | |
| For all others | ||
| PPO Providers | $3,750 per family | |
| Non-PPO Providers | $7,500 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 (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. | ||
| *Note: You must use PPO providers when receiving preventive, well-care services. | ||
| 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 | |
| Mental Health/Substance Abuse Treatment (pre-certification required)** | ||
| Lifetime Maximum for Substance Abuse Treatment | Unlimited | |
| Mental Health/Substance Abuse Outpatient Treatment | Fund pays 50% of covered charges. | |
| 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. | |
**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.
