High Deductible Health Plan

1. Deductible per calendar year.

1. Once the OOP maximum is met, benefits are provided at 100% for a member for the remainder of the calendar year. This applies to in-network provider services only.

Unlimited calendar year maximum per member

• Generic or Brand | Farm Bureau Health Plans will reimburse 80% of the maximum allowable charge, after CYD.
• Home Delivery service is also available
• Broad Formulary
• Members may use pharmacy of choice for brand name and/or generic prescriptions; specialty drugs are provided through Optum Specialty Pharmacy.

1. Benefits are available, subject to deductible and coinsurance, for a member under the age of 7 (on plan deductibles $3,000 and $5,000) for physical examinations and appropriate immunizations/vaccinations when services are rendered by an in-network provider. Exams not used during the time periods below do not carry over to the next time period.
• Physical Examination Guidelines
  • Under age 1: 4 exams from birth to the child's first birthday
  • Age 1: 2 exams from the child’s first birthday to the child’s second birthday
  • Age 2 - 6: 1 exam per year (determined by the child’s birthday)

1. Benefits will be available, subject to deductible and coinsurance, for one routine OB/GYN exam per calendar year. Services must be rendered by an in-network physician’s office and billed by the in-network provider. Related pathology, including pap smear, which is provided as a part of the routine OB/GYN exam, will be covered when the services are rendered by an in-network physician’s office and billed by the in-network provider. Related pathology that the physician sends to an independent laboratory will be subject to deductible and coinsurance. No benefit is available for routine OB/GYN exams provided by an out-of-network provider.

1. Benefits will be provided for 1 routine colonoscopy every 4 years for members age 50 and over when provided by an in-network or out-of-network provider, subject to the deductible and coinsurance.

1. Benefits will be provided, subject to deductible and coinsurance, for 1 routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.

1. Benefits will be provided, subject to deductible and coinsurance, for the interpretation of 1 routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting.

1. Benefits will be provided, subject to deductible and coinsurance, for routine mammography screening provided such examinations are conducted upon the recommendation of the member’s physician. One baseline routine mammogram will be allowed for members between the ages of 35-39. One routine mammogram will be allowed annually for members age 40 and above.

Maternity Benefits will be available after a member’s coverage on a 2-person, 3-person or family contract has been in effect for nine consecutive months. Individual coverage has NO maternity benefits.

Benefits will not be provided for any pre-existing condition until a member has completed a waiting period of at least 12 months. A pre-existing condition is defined in the contract as “An illness, injury, pregnancy or any other medical condition which existed at any time preceding the effective date of coverage under this contract for which: Medical advice or treatment was recommended by, or received from, a provider of health care services; or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.” The pre-existing condition waiting period will apply to all members listed on the contract.