Fraternal Order of Police
Fort Lauderdale Lodge # 31
HEALTH TRUST

735 NE 3rd Avenue
Fort Lauderdale, Florida 33304
FOP Health Trust (954) 527-9218
 

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Fort Lauderdale FOP Lodge 31

Fort Lauderdale Fraternal Order of Police

ASO Choice Modified Plan 012

Choice plan gives you the freedom to see any Physician or other health care professional from the Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills.

Some of the Important Benefits of Your Plan:

You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral.

Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery.

Care Coordination^SM services are available to help identify and prevent delays in care for those who might need specialized help.

• Emergencies are covered anywhere in the world.

• Pap smears are covered.

• Prenatal care is covered.

• Routine check-ups are covered.

• Childhood immunizations are covered.

• Mammograms are covered.

• Vision and hearing screenings are covered.

Choice Benefits Summary

Types of Coverage		Network Benefits /Copayment Amounts
This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your health care expenses. More complete descriptions of Benefits and the terms under which they are provided are contained in the Summary Plan Description that you will receive upon request from your Benefits Manager. If this Benefit Summary conflicts in any way with the Summary Plan Description issued to your employer, the Summary Plan Description shall prevail. Terms that are capitalized in the Benefit Summary are defined in the Summary Plan Description. Benefits are payable for Covered Health Services provided by or under the direction of your Network physician. *Prior Notification is required for certain services.		Annual Deductible: $100 per Covered Person per calendar year, not to exceed $300 for all Covered Persons in a family.
		Out-of-Pocket Maximum: Out-of-Pocket Maximum: $1,000 per Covered Person per calendar year, not to exceed $3,000 for all Covered Persons in a family. The Out-of-Pocket Maximum does not include the annual Deductible. Copyaments for some Covered Health Services will never apply to the Out of-Pocket Maximum as specified in Section 1 of the SPD.
		Maximum Plan Benefit: No Maximum Plan Benefit.
1. Ambulance Services - Emergency only		Ground Transportation: No Copayment Air Transportation: No Copayment
2. Dental Services - Accident only		*No Copayment *Prior notification is required before follow-up treatment begins.
3. Durable Medical Equipment Benefits for Durable Medical Equipment are limited to $2,500 per calendar year.		20% of Eligible Expenses after deductible
4. Emergency Health Services		*$100 per visit Copay waived if admitted. Please note that if you are admitted to a non-Network Hospital, you must notify Care Coordination within one business day, or as soon as possible. *Prior notification is required.
5. Eye Examinations Refractive eye examinations are limited to one every other calendar year from a Network Provider.		$30 per visit
6. Home Health Care Benefits are limited to 60 visits for skilled care services per calendar year.		20% of Eligible Expenses after deductible
7. Hospice Care Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the Plan.		No Copayment
8. Hospital - Inpatient Stay		*$250 per Inpatient Stay per day (up to 2 days maximum) If your doctor who is performing any of the procedures while in the hospital is a non-network provider, the whole event is not covered. *Prior notification is required.
9. Injections Received in a Physician’s Office		No Copayment
10. Maternity Services		*Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for prenatal care after the first visit. *Prior notification is required.
11. Outpatient Surgery, Diagnostic and Therapeutic Services
Outpatient Surgery		$100 per visit
Outpatient Diagnostic Services		For lab and radiology/Xray: No Copayment For mammography testing: No Copayment
Outpatient Diagnostic/Therapeutic Services - CT Scans, Pet Scans,  MRI and Nuclear Medicine		No Copayment
Outpatient Therapeutic Treatments (Dialysis, intravenous chemotherapy or other intravenous infusion therapy, etc).		No Copayment
12. Physician’s Office Services		PCP:  $20 per visit. No Copayment applies when a Physician charge is not assessed. Specialist:  $30 per visit
13. Professional Fees for Surgical and Medical Services		No Copayment
14. Prosthetic Devices Benefits for prosthetic devices are limited to $2,500 per calendar year.		*20% of Eligible Expenses after deductible
15. Reconstructive Procedures		Same as 8, 11, 12, 13 and 14
16. Rehabilitation Services -Outpatient Therapy Benefits are limited as follows: 40 visits of physical therapy; 40 visits of occupational therapy; 40 visits of speech therapy; 40 visits of pulmonary rehabilitation; and 40 visits of cardiac rehabilitation per calendar year.		$20 per visit
17. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Benefits are limited to 60 days per calendar year.		No Copayment
18. Transplantation Services		No Copayment
19. Urgent Care Center Services		$30 per visit
20. Pharmacy		Retail (Mandatory generic drugs): $10 copay – generic $25 copay – brand, preferred $40 copay – brand, non-preferred   Mail Order (Mandatory mail order for maintenance drugs after a 90 day retail period for new prescriptions, and mandatory generic drugs): $20 copay – generic $50 copay – brand, preferred $80 copay – brand, non-preferred
Additional Benefits
Mental Health and Substance Abuse Services – Outpatient Must receive prior authorization through the Mental Health/Substance Abuse Designee.  Benefits are limited to 20 visits per calendar year.		*$30 per individual visit; $25 per group visit. *Prior notification is required.
Mental Health and Substance Abuse Services – Inpatient and Intermediate Must receive prior authorization through the Mental Health/Substance Abuse Designee.  Benefits are limited to 30 days per calendar year.		*$250 per Inpatient Stay per day (up to a 2 day maximum) *Prior notification is required.
Spinal Treatment/Chiropractic Care Benefits include diagnosis and related services and are limited to one visit and treatment per day.  Benefits are limited to 20 visits per calendar year.		$30 per visit
Gastric Bypass		Not Covered
Infertility		Not Covered

Except as may be specifically provided in Section 1 of the Summary Plan Description (SPD) or through a Rider to the Plan, the following are not covered:

A. Alternative Treatments

Acupressure; hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and other forms of alternative treatment.

B. Comfort or Convenience

Personal comfort or convenience items or services such as television; telephone; barber or beauty service; guest service; supplies, equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech.

C. Dental

Except as specifically described as covered in Section 1 of the SPD for services to repair a sound natural tooth that has documented accident-related damage, dental services are excluded. There is no coverage for services provided for the prevention, diagnosis, and treatment of the teeth, jawbones or gums (including extraction, restoration, and replacement of teeth, medical or surgical treatments of dental conditions, and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x-rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, or the direct treatment of acute traumatic Injury, cancer, or cleft palate. Treatment for congenitally missing, malpositioned, or super numerary teeth is excluded, even if part of a Congenital Anomaly.

D. Drugs

Prescription drug products for outpatient use that are filled by a prescription order or refill. Self-injectable medications. Non-injectable medications given in a Physician’s office except as required in an Emergency. Over-the-counter drugs and treatments.

E. Experimental, Investigational or Unproven Services

Experimental, Investigational or Unproven Services are excluded. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

F. Foot Care

Routine foot care (including the cutting or removal of corns and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the foot; shoe orthotics.

G. Medical Supplies and Appliances

Devices used specifically as safety items or to affect performance primarily in sports-related activities. Prescribed or non-prescribed medical supplies and disposable supplies including but not limited to elastic stockings, ace bandages, gauze and dressings, ostomy supplies, syringes and diabetic test strips. Orthotic appliances that straighten or re-shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section 1 of the SPD.

H. Mental Health/Substance Abuse

Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other disorders with a known physical basis.

Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee.

Services utilizing methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example, consistent with certain national standards or professional research further described in Section 2 of the SPD.

I. Nutrition

Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk.

J. Physical Appearance

Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, and/or which are performed as a treatment for acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy.)

Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical and non-medical reasons. Wigs, regardless of the reason for the hair loss.

K. Providers

Services performed by a provider with your same legal residence or who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free-standing or Hospital-based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the SPD (this exclusion does not apply to mammography testing).

L. Reproduction

Health services and associated expenses for infertility treatments.

Surrogate parenting. The reversal of voluntary sterilization.     

M. Services Provided under Another Plan

Health services for which other coverage is required by federal, state or local law to be purchased or provided through other arrangements, including but not limited to coverage required by workers’ compensation, no-fault automobile insurance, or similar legislation. If coverage under workers’ compensation or similar legislation is optional because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Mental Illness or Sickness that would have been covered under workers’ compensation or similar legislation had that coverage been elected.

Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty.

N. Transplants

Health services for organ or tissue transplants are excluded, except those specified as covered in Section 1 of the SPD. Any solid organ transplant that is performed as a treatment for cancer.

Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs.

Transplant services that are not performed at a Designated Facility. Any multiple organ transplant not listed as a Covered Health Service in Section 1 of the SPD.

O. Travel

Health services provided in a foreign country, unless required as Emergency Health Services.

Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion.

P. Vision and Hearing

Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial keratotomy, laser, and other refractive eye surgery.

Q. Other Exclusions

Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the SPD.

Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Plan, when such services are: (1) required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type.

Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising prior to the date your coverage under the Plan ends.

Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan.

Charges in excess of Eligible Expenses or in excess of any specified limitation.

Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be medical or dental in nature.

Upper and lower jaw bone surgery except as required for direct treatment of acute traumatic Injury or cancer. Orthognathic surgery, jaw alignment, and treatment for the temporomandibular joint, except as a treatment of obstructive sleep apnea.

Surgical treatment and non-surgical treatment of obesity (including morbid obesity).

Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea. Oral appliances for snoring.

Custodial care; domiciliary care; private duty nursing; respite care; rest cures.

Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke or Congenital Anomaly.