Benefits

The Toledo Firefighters Health Plan provides coverage in the form of Medical Care, Vision, Dental, Prescription Drug and Loss-of-Life Insurance.  The complete description of the plan can be reviewed in the Summary Plan Description, downloadable below.

Summary Plan Description

A new SPD will be available soon. Please view the brief description below for details. If you have any questions please call the Plan Office at 419-255-5314.


VISION

 Spectera Vision Program details
 Spectera Coordination of Benefits

If you have any questions about the Plan which you wish to discuss, please contact the Plan Office at 419-255-5314.

Summary Plan Index

Schedule of Benefits

There is a maximum lifetime benefit of $1,000,000 per individual 

Benefit

Coverage

Limitation

  
Loss-of-Life Insurance $20,000.00 (Firefighter only)  

Benefit

Description

Coverage

Limitation 

Dental Care Prevention Expenses 100% RC Twice per year
  Fluoride Treatment 100% RC Adults - limit 1 per calendar year
Dependent Children - limited 2 per calendar year (0-19 yrs.)
  Emergency Treatment 100% RC To alleviate pain
  Routine Restorative 80% RC $25 Deductible and $1250 max per year
  Orthodontic 50% RC Dependent Children to age 19: $2000 lifetime max
  Night Guard (grinding) 50% RC Once in a lifetime

Benefit

Description

Coverage

Limitation 

Prescription Drugs Generic   $5 See Exclusions Section for Details
  Brand Preferred $15 (formulary)
  Brand Non Preferred $30 (non-formulary)

Benefit

Coverage

Limitation

Hearing Aids   $750 $750 lifetime max

Benefit

Description

Coverage

Limitation

Hospitalization Room & Board Preferred Provider facility 100% according to UR approval no deductible
  Non-Preferred Provider Hospital non-emergency  80%  
  Emergency Care 100% RC $50 deductible *waived if services are a result of an injury accident, admission or 23-hour observation*
  Urgent Care 100% RC *unless visit occurs during regular office business hours which will then be covered at 90% RC*
  Non-Preferred Provider 80% RC unless visit occurs during regular business hours which will then be covered at 70% RC
Hospitalization (Cont.) Intensive, Coronary Care 100% RC
80% RC		 P.P.O.
Out of network
  Surgery Surgeon, and  Assistant Surgeon 100% RC
80% RC		 P.P.O.
Out of network
  Anesthesiology 100% RC
80% RC		 P.P.O.
Out of network
  In-Hospital Physicians 100% RC
80% RC		 P.P.O.
Out of network
  Maternity 100% RC
80% RC		 P.P.O.
Out of network
  Diagnostic Testing 100% RC
80% RC		 P.P.O.
Out of network
  Physical Respiratory Therapy 100% RC
80% RC		 P.P.O.
Out of network
  Chemotherapy, radiation Therapy 100% RC80% RC P.P.O.
Out of network
  *See Frontpath directory for a list of approved facilities.

Benefit

Description

Coverage

Limitation

Extended Care Facilities Convalescent Care Maximum time from Hospital Discharge to Convalescent Admission 10 days 100% RC 100 days maximum
P.P.O.
Hospice Care   100%  RC  
80%  RC		 P.P.O.
Out of network 

Benefit

Coverage

Limitation

Home Health Care
   100% RC  
80% RC		 P.P.O.
Out of network 
  *All Home Health Care Requires Pre-Certification
  * See Frontpath directory for a list of approved facilities 

Benefit

Coverage

Limitation

Physician Office Visits & Procedures In-Network 90% RC P.P.O.
No Co-Pay
  Out-of-network 70% RC  

Benefit

Coverage

Limitation

Outpatient Care Ambulatory Surgery 100% RC
80% RC		 P.P.O.
Out of network 
  Pre-Admission Testing 100% RC
80% RC		 P.P.O.
Out of network 
  Second Surgical Opinions 100% RC Contact Plan office prior to appointment

 Benefit

Coverage

Limitation

Chiropractic Services In network 90% RC $750 per calendar year maximum
  Out of network 80% RC  
  X-rays 50% RC Only 2 per diagnosis
 *See Frontpath directory  for a complete list of chiropractic physicians
       

Benefit

Coverage

 

Limitation

Mental & Nervous Disorders  *** Call Health Plan Office for authorization.
All psychological testing must be pre-approved
  Inpatient Treatment   Limited to 31 days per year
Approved Facility Non-Approved  
First Admission 100% 80% RC  
Second Admission 70% 50% RC  
Third Admission 40% 20% RC  
    
Outpatient Treatment 100% RC at preferred facility. A maximum of 20 visits allowed per year.
80% UCR at a non-preferred facility.  A maximum of 15 visits allowed per year.  Must call Health Plan Office for authorization.
       
Office Visits $14 co-pay/PHD  Panel Provider  20 visits total calendar year maximum
  $18 co-pay/MD Panel Provider 15 visits total calendar year maximum
80% of allowable charges Non-panel Provider but is a Frontpath PPO provider
80% RC Non-panel provider
Non-Frontpath provider 		15 visits total calendar year maximum
MUST CALL HEALTH PLAN OFFICE FOR AUTHORIZATION *Outpatient treatment and office visits are combined and payable at 15 or 20 visits per year depending on provider used.*  

Benefit

Coverage

 

Limitation

Substance Abuse and Chemical Dependency ***Call Health Plan Office for authorization All psychological testing must be pre-approved  
Inpatient Treatment     Limited to 31 days per year
   Approved Facility Non-Approved  
First Admission 100% 80% RC  
Second Admission 70% 50% RC  
Third Admission 40% 20% RC  
       
Outpatient Treatment 100% RC at preferred facility.    A maximum of 20 visits allowed per year.
   80% UCR at a non-preferred facility.    A maximum of 15 visits allowed per year.
Must call Health Plan Office for authorization.
Office Visits $14 co-pay/PHD
$18 co-pay/MD		 Panel Provider
Panel Provider		 20 visits total calendar year maximum
  80% of allowable charges Non-Panel Provider but is Frontpath PPO Provider 15 visits total calendar year maximum
  80% RC Non-Panel Provider
Non-Frontpath provider		 15 visits total calendar year maximum
MUST CALL HEALTH PLAN OFFICE FOR AUTHORIZATION. *Outpatient treatment and office visits are combined and payable at 15 or 20 visits per year depending on provider used.*

Benefit

Description

Coverage

Limitation
Wellness Care      
  Colonoscopy Screening  *Must contact the Plan Office for prior authorization 80% of contracted rate at preferred provider selected by Health Plan for eligible members.  Refer to list of eligibility requirements.  This test will ONLY be covered using the Preferred Provider selected through the Health Plan
  Fetal Occult Blood Test Screening 90% in network
70% RC - out of network		  
  Flexible Sigmoidoscopy Screening  80% in network
70%/RC - out of network		  
  Routine Physical Exams Firefighters age 33 and over, one every three years at approved facility.   (Must have completed 18 months on job).
  Routine Spousal Physical Exam One every three years at approved facility. Age 40 and over with co-pay of $100.00
  Well Child Care - Visits and Procedures One visit per calendar year at 100% RC including immunizations for dependents age 0-19 years. Dependents age 0-7 years, additional visits covered at  90% RC - PPO                          70% RC - Outside of network

Dependents age 8-19 years, additional visits NOT covered  Sports physicals are covered through age 19 as long as combined with the one allowed Well Child visit per calendar year. 
  Mammograms 100% RC PPO  
70% RC Out of network		  
  Gynecological Visits and Procedures 100% RC limited to one annually PPO
  Contraceptives All methods of Contraceptives covered under RX Plan according to co-pay structure.
  Allergy Injections  100% RC PPO
80% RC Out of network		  
   *See Frontpath directory for a list of approved facilities.

Benefit

Coverage

 

Limitation
Laboratory Outpatient & Office Visit In Network  90% RC PPO
  Out-of-network 70$ RC Out-Of-Network
  *See Frontpath directory for a list of approved facilities.

Benefit

 

Coverage

Limitation
Radiology Outpatient & Office Visits      
   In Network
out of Network		 100%   
70%		  PPO
Out-of-network 
  *See Frontpath directory for a list of approved facilities.

Benefit

Description

Coverage

Limitation
Other Types of Care Physical Therapy 100% RC
80% RC		 PPO
Out-of-network 
  Speech Therapy 100% RC
80% RC		 PPO
Out-of-network 
  Occupational Therapy 100% RC
80% RC		 PPO
Out-of-network 
       
  Surgical Sterilization 100% RC
80% RC		 PPO
Out-of-network 
  Local Ambulance 80% RC  
  Organ Transplant 80% RC
Prior approval of Plan Administrator required: Non-Experimental only at approved facility		 PPO
$120,000 maximum.
  HIV / AIDS $50,000 lifetime maximum PPO
  Durable Medical Equipment rental or purchase *Must have a physicians script*   80% RC
70% RC		 PPO
Out-of-network
  Nutritional Supplements 80% RC For covered dependents only if medical necessity requires such feeding by means other than oral ingestion and necessity is certified by Plan consultant pursuant to Rx from physician. PPO
  *See Frontpath directory for a list of approved facilities 
Cost Containment There are Special Cost Control Provisions which must be met in order to qualify for maximum benefits.  These include the following:  
  Failure to Pre-certify: 20% reduction in benefits
  Pregnancy must call within first 3 months of pregnancy.  
Hospital/Physician Preferred Provider Network In order to keep costs under control and to provide quality medical care, the Health Plan has established a preferred provider network for various medical services.

*See Frontpath directory for a list of approved facilities.
Mental Health Preferred Providers There is a preferred provider network for outpatient care for mental health and substance abuse. These providers have agreed to discount their fees to the Plan and are subject to treatment guidelines as established by our mental health committee.

All psychological testing must be pre-approved by calling the Health plan Office
       
       

 

Healthy Living Tip

Dehydrated? Avoid sodas and alcohol. Best ways to rehydrate are water or fruit juice.
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Q & A

What should I have ready when I call the Plan office?

Please have you ID card and any documents regarding the claims or issue you are calling to discuss. More