Summary Plan Description
Toledo Fire Fighters Health Plan
Summary
Schedule of Benefits
There is a maximum lifetime benefit of $450,000 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: $1500 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 | $25 | (non-formulary) | |
| Benefit | Description | Coverage | Limitation |
| Hearing Aids | |||
| $250 | $250 lifetime max-firefighter only | ||
| Benefit | Description | Coverage | Limitation |
| Vision Care | |||
| Examination |
$25 per year |
one exam per visit used towards corrective lenses | |
| Materials | $50 per year | ||
| 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 |
|
| Intensive, Coronary Care |
100% RC 80% RC |
P.P.O. Out of network |
|
| Surgery Surgeon, and Assistant Surgeon |
100% 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% 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 | Description | Coverage | Limitation |
| Home
Health Care *All Home Health Care Requires Pre-Certification |
|||
| 100% RC 80% RC |
P.P.O. Out of network |
||
|
* See Frontpath directory for a list of approved facilities |
|||
| Benefit | Description | Coverage | Limitation | |
| Physician Office Visits & Procedures | ||||
| In-Network Out-of-network |
90% RC 70% RC |
P.P.O. No Co-Pay |
||
| *See Frontpath directory for list of physicians | ||||
| Benefit | Description | 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 | Description | 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 | Description | 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 Second Admission Third Admission |
100% 70% 40% |
80% RC 50% RC 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 a 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 |
| 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 Second Admission Third Admission |
100% 70% 40% |
80% RC 50% RC 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 a Frontpath PPO provider | 15 visits total calendar year maximum | |
| 80% RC |
Non-panel provider Non-Frontpath provider |
15 visit 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.* |
|||
| 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 (MORE INFORMATION) |
||
| 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. |
|||
| Laboratory Outpatient & Office Visit |
In Network out of Network |
90% RC 70% RC |
PPO Out-of-network |
| *See Frontpath directory for a list of approved facilities. | |||
| Radiology
Outpatient & Office Visits |
In Network out of Network |
100% 70% |
PPO Out-of-network |
|
*See Frontpath directory for a list of approved facilities. |
|||
| 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% |
PPO Out-of-network |
||
| Surgical Sterilization |
100% RC 80% RC |
PPO Out-of-network |
||
| Local Ambulance | 80% RC | |||
| Organ Transplant |
80% RC $50,000 maximum Prior approval of Plan Administrator required: Non-Experimental only at approved facility |
PPO |
||
| 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 | ||
|
*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. |
Final Note:
Remember to call the Health Plan Office at 419-255-5314 for any and all questions!