Highlights of your Health Care Coverage

Transcription

1 Highlights of your Health Care Coverage Spokane Firefighters Pension Board Group Number: Effective Date: 01/01/2018 All services must be furnished in connection with either the prevention or diagnosis and treatment of a covered illness, disease or injury. Please refer to the Group Benefit booklet for the full definition of medically necessary and allowable charges. MEDICAL PLAN *ACA Exempt MEDICAL COST SHARE OPTIONS Individual Deductible PCY Coinsurance ALL PROVIDERS Individual Out of Pocket Maximum PCY Not applicable Office Visit Cost Share COVERED SERVICES PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION Preventive Office Visit Immunizations Health Education ($250 PCY) Nicotine Dependency Programs Diabetes Health Education PROFESSIONAL CARE Professional Office Visit Inpatient Professional Services DIAGNOSTIC SERVICE OPTIONS Preventive Professional and Other Professional Diagnostic Imaging and Laboratory Services Outpatient Mammography (Screening an Diagnostic) FACILITY CARE OPTIONS 0% 1-9GWSJ7 Rev #1 Q 10/6/ :43 AM Page 1 of 3

2 MEDICAL PLAN *ACA Exempt Inpatient Facility Outpatient Surgery Facility Skilled Nursing Facility Hospice Inpatient Facility (6 month limit) EMERGENCY CARE AND TRANSPORTATION OPTION Outpatient Emergency Emergency Room Physician Urgent Care Facility Ambulance Transportation Air Ambulance OTHER SERVICES Acupuncture (24 Visits PCY) Chemical Dependency Care Home Health Visits Hospice Care (Respite: 240 hours; within the 6 month limit) Manipulations: Spinal and Other (24 Visits PCY) Medical Supplies, Equipment, Prosthetics (Orthotics $300 PCY; Includes orthotics and orthopedic shoes) Mental Health Care Orthognathic/Maxillofacial Care ($5,000 Lifetime) Rehab Inpatient Facility Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy; Cardiac & Pulmonary Rehab.; and Chronic Pain (45 Visits PCY) TMJ (Temporomandibular Joint Disorders) ($1,000 PCY/$5,000 per Lifetime) Transplants SUPPLEMENTAL BENEFITS Routine Vision Exam (1 PCY) Vision Hardware ($500 every 2 Calendar Years) Lasik Eye Surgery ($2,600 Lifetime Maximum) Toric and Multifocal Lens (implanted after Cataract Surgery) (2 Units) Hearing Exam (1 PCY) Hearing Hardware ($5,500 every 5 years) LIFETIME MAXIMUM ALL PROVIDERS *This plan is self-funded by Spokane Firefighters Pension Board, which means that this group is financially responsible for the payment of plan benefits. The group has contracted with Premera Blue Cross, an independent Licensee of the Blue Cross Blue Shield Association, to perform administrative duties, including the processing of claims, under the plan. Premera Blue Cross does not insure the benefits of this plan. Any coinsurance amounts based on a percentage of allowable charges. You may be responsible for additional charges if a provider is not contracted with Premera Blue Cross PCY = Per Calendar Year *Premera Blue Cross believes this plan is a grandfathered health plan under the Affordable Care Act 1-9GWSJ7 Rev #1 Q 10/6/ :43 AM Page 2 of 3

3 Highlights of your Health Care Coverage Spokane Firefighters Pension Board Group Number: Effective Date: 01/01/2018 PHARMACY PLAN Below is a brief overview of what you can expect to pay for a prescription drug. For more information on your pharmacy benefits, including Non-Participating Retail Pharmacies, see your benefit booklet. OUTPATIENT PRESCRIPTION DRUGS COST SHARE Drug List Open A2 Tier 1 = generic Tier 2 = brands Retail Pharmacy (Includes medically necessary Over-the-Counter Drugs purchased at a participating pharmacy and prescribed by a physician) Dispensing Limit Up to a 365-day supply unit supply of covered medication unless the drug maker s packaging limits the supply in some other way. Mail Order Up to 90 day supply per prescription Out of Network (Non-participating retail pharmacies) Out of Pocket Maximum Annual Benefit Maximum *This plan is self-funded by Spokane Firefighters Pension Board, which means that this group is financially responsible for the payment of plan benefits. The group has contracted with Premera Blue Cross, an independent Licensee of the Blue Cross Blue Shield Association, to perform administrative duties, including the processing of claims, under the plan. Premera Blue Cross does not insure the benefits of this plan. PCY = Per Calendar Year. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-9GWSJ7 Rev #1 Q 10/6/ :43 AM Page 3 of 3

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