Philly Fire’s Motivated Fitness » Health Plan

Health Plan

We know how important good, comprehensive health benefits are.  The coverage under the Local 22 Health Plan gives you the security of knowing that you and your family are protected against high out-of-pocket expenses when you need treatment.  Here are details on your Health Plan benefits:

Overview of Health Plan Benefits

Plan Description
Medical Personal Choice PPO or Keystone Health Plan East (HMO) administered by Independence Blue Cross
Prescription Drug You pay $5 for generic, $10 for preferred brand, and $15 for non-preferred brand at retail pharmacy.  Mail order is 2 times the retail copay.  Both Benecard CentralFill and Rite Aid retail pharmacies can provide a prescribed 90 day supply of maintenance medication
Dental Dental PPO or Dental HMO (DHMO)
Vision You may receive a vision exam and lenses once every year and frames once every 2 years
Laser Eye Surgery The Plan pays 80% up to a maximum allowable charge of $2000 per eye (maximum reimbursement of $1600 per eye).  This is a member-only benefit
Hearing Aid You may  receive 100% of the cost of a hearing aid, up to a maximum of $500 per ear, 1x every 5 years.  This is a member-only benefit
Employee Assistance Program (EAP) The Plan pays 100% for up to 5 face-to-face visits, per issue,  with a trained mental health professional
Other Benefits The Plan provides an advocacy benefit, administered through Health Advocate, to help you and your family members with healthcare and health insurance issues
The plan offers telemedicine services (MeMD) that allows you to reach a medical provider via telephone or web 24/7, 365 days a year

Medical Plan Benefits

Here is a summary of the benefits provided under the PPO and the HMO medical plans.  For additional details on any benefit limit or exclusions please contact Independence Blue Cross or the Health Plan Office

PPO Medical Plan HMO Medical Plan
Plan Feature In-Network Out-of-Network1 In-Network
Annual Deductible $0 per individual $250 per individual $0 per individual
$0 per family $500 per family $0 per family
Out-of-Pocket Maximum $1,000 per individual $1,000 per individual $1,000 per individual
$2,000 per family $2,000 per family
Lifetime Maximum Unlimited Unlimited Unlimited
Physician Services
Primary care office visit $15 copayment 80% after deductible $15 copayment
Specialist office visit $25 copayment 80% after deductible $25 copayment
Preventive Care (for adults and children) 100% 80% after deductible 100%
Pediatric Immunizations 100% 2 80%, no deductible 100% 2
Routine Gynecological Exam and Pap test (1 per calendar year for women of any age) 100% 80%, no deductible 100% (no referral required)
Mammogram 100% 80%, no deductible 100% (no referral required)
Inpatient and Outpatient Services
Maternity
First OB Visit $15 copayment 80% after deductible $0 copayment
Hospital 100% 80% after deductible 100%
Inpatient Hospital Services
Facility 100% 80% after deductible 100%
Physician/Surgeon 100% 80% after deductible 100%
Inpatient Hospital Days Unlimited 70 Unlimited
Outpatient Surgery
Facility 100% 80% after deductible 100%
Physician/Surgeon 100% 80% after deductible 100%
Skilled Nursing Facility 100% 80% after deductible 100% up to 180 days per calendar year
Emergency Room $25 copayment (waived if admitted) $25 copayment, no deductible, copay waived if admitted $25 copayment (waived if admitted)
Urgent Care Center $17 copayment 80% after deductible $17 copayment
Ambulance
Emergency 100% when medically necessary 100%, no deductible 100% when medically necessary
Non-emergency 100% when medically necessary 80% after deductible 100% when medically necessary
Outpatient Laboratory 100% 80% after deductible 100%
Outpatient Radiology 100% 80% after deductible 100%
Therapy Services
Physical, Speech, Occupational $10 copayment 80% after deductible 100%.  Up to 60 consecutive days per condition covered, subject to significant improvement
Pulmonary Rehabilitation $10 copayment 80% after deductible 100%
Respiratory therapy $10 copayment 80% after deductible 100%
Restorative services, including chiropractic care $25 copayment 80% after deductible 100%.  Up to 60 consecutive days per condition covered, subject to significant improvement
Other Services
Home Health Care 100% 80% after deductible 100%
Durable Medical Equipment 100% 80% after deductible 100%
Mental Health Care
Inpatient 100% 80% after deductible 100%
Outpatient $25 copayment 80% after deductible $25 copayment
Substance Abuse Treatment
Inpatient 100% 80% after deductible 100%
Outpatient $25 copayment 80% after deductible $25 copayment

1 Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence Blue Cross, and the actual charge of the provider.
2 Office visit subject to payment

Prescription Drug Plan Benefits

Here is a summary of your prescription drug benefit.  For additional details on any benefit limit or exclusion, please contact Benecard or the Health Plan office

Prescription Drug Category Retail Pharmacy Mail Order *
Generic $  5 copay for up to a 30-day supply $ 10 copay for up to a 90-day supply
Preferred Brand Name $ 10 copay for up to a 30-day supply $ 20 copay for up to a 90-day supply
Non-preferred Brand Name $ 15 copay for up to a 30-day supply $ 30 copay for up to a 90-day supply

* In addition to Benecard Central Fill, the mail order facility, you can fill presctriptions for your 90-day maintenance medications at your local Rite Aid retail pharmacy

Dental Plan Benefits

Here is a summary of your dental plan benefits.  For additional details on any benefit limit or exclusion, please contact Aetna or the Health Plan office

PPO DMO
In-network Out of network*
Annual Deductible
Individual None None None
Family None None None
Preventive Services 100% 100% 100%
Basic Services 100% 100% 100%
Major Services 100% 100% 100%
Dental Implants 100% 100% Not Covered
Annual Benefit Maximum** $5,500 None
Office Visit Copay N/A N/A $0
Orthodontic Services 100% 100% 100%
Orthodontic Deductible None None None
Orthodontic Lifetime Maximum** $4,000 $4,000 None

*Out of Network services reimbursed at % of allowed charge.  Out of network providers may bill you for the difference between amount charged and amount paid by Aetna.
**Annual and Lifetime Maximums are total of in-network and out-of-network treatment combined

Vision Plan Benefits

Here is a summary of your vision plan benefits.  For additional details on any benefit limit or exclusion, please contact VBA or the Health Plan office

Participating Provider Non-Participating Provider
ROUTINE EXAM
(for glasses) Once every 12 months Covered 100% Reimbursedup to $36
LENSES Standard Glass or Plastic
(once every 12 months)
Single Vision 100% Up to $32
Bifocal 100% Up to $65
Blended Bifocals 100% Up to $65
Progressive (except digital) 100% Up to $65
Trifocal 100% Up to $65
Lenticular 100% Up to $65
Polycarbonate (under age 19) 100% N/A
2 Yr. Scratch Protection 100% N/A
UV 400 100% N/A
Tints 100% N/A
FRAME
Once every 24 months Covered 100% if within the plan’s wholesale allowance Up to $40
OR
CONTACT LENSES In lieu of all other materials/services* In lieu of all other materials/services*
(once every 12 months)
Elective Contact Lenses Up to $160 Up to $160
Medically Necessary UCR Up to $300
(requires prior authorization from VBA) (usual, customary and reasonable)

* The contact allowance is applied to all services/materials associated with contact lenses.  This includes, but is not limited to, exam, fitting, dispensing, cost of lenses, etc.

Whom to Call

I.A.F.F.  LOCAL  22

 THE PHILADELPHIA FIRE FIGHTERS UNION

 HEALTH PLAN

 SUMMARY PLAN DESCRIPTION

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