Teamsters Local 20 members enroll in the City of Toledo's health plan, effective November 1, 2010.
(a) General Provisions: The City shall provide hospital, medical, surgical, outpatient diagnostic laboratory services, prescription drug, dental and vision care and benefits under the terms and conditions set forth below. The Union membership shall provide monthly contributions - single $25.00, single plus one, $40.00 and family, $55.00. This contribution takes effect the first month after implementation.
(b) Coverage shall be provided to each employee, each employee's spouse and all unmarried dependent members of the employee's family to age twenty-six (26). Spouses who are both employed by the city must jointly elect only one coverage. A new election may occur after an open enrollment due to circumstances such as layoff or other separation of one of the spouses, death, or divorce. Where spouses who are both employed have dependents from prior marriages for whose hospitalization coverage they are responsible shall be exempt from this joint election requirement.
Where the spouse of a City employee has health care coverage through a different employer, the spouse must enroll in his/her employer's plan. Dependents shall be covered as provided by the "birthday rule".
In cases of demonstrated hardship due to excessive co-premiums (e.g., spouse's annual income is less than $30,000 and they have to pay 40% or more of the employee's premium payment), special consideration will occur.
(c) Coverage for this purpose shall be an insurance carrier selected exclusively by the City.
(d) Second surgical opinions, pre-admission notification or certification, emergency care limitations, post admission concurrent review, outpatient surgery, continued treatment and technological review, medical case management, planned discharge, and other procedures as may be established under the medical review programs established by the city shall be followed. Failure to follow the procedures shall result in only eighty percent (80%) coverage for necessary care.
(e) The panel of providers, and/or preferred provider organization (P.P.O.), selected by the city for managing and providing services must be utilized.
(f) The following cost sharing plan and cost coverage restrictions shall be effective for all employees:
(i) There shall be a five hundred dollar ($500.00) annual per person maximum on chiropractic care and a one thousand three hundred dollar ($1,300.00) annual per person maximum on physical therapy, both subject to the major medical deductible ($100/individual and $200/family) and co-insurance (80%/20%).
(ii) Major medical benefits shall be paid to a lifetime maximum of one million dollars ($1,000,000.00) per person with a one hundred dollar ($100.00)/individual and two hundred dollar ($200.00)/family deductible and 80%/20% co-payment.
(iii) There shall be a sixty-five dollar ($65.00) co-pay for all emergency room visits, which shall be waived if the individual is admitted or if the visit is between the hours of 8:00 p.m. and 9:00 a.m., or on a Saturday after 12:00 noon, or on a Sunday.
(g) Coverage for well baby care, pap tests, and office visits shall be offered to all employees enrolled under conventional coverage as follows:
(i) Well baby care limited to routine examinations and immunizations for an infant until the infant's 1st birthday;
(ii) Pap tests as well as office fee will be paid in full once every twelve (12) months;
(iii) Office visits for routine wellness services and treatment of illness or injury rendered in the physicians office, including physical examinations and family planning shall be subject to a fifteen dollar ($15.00) co-payment, which shall be counted toward the individual's major medical deductible;
(h) Fees that the physician charges for the services under paragraphs (i), (ii), and (iii) shall be paid on the same basis as other covered services (e.g. usual, customary, and reasonable). Payment for services under Part (f)(i) and (iii) will be made for the first one hundred twenty-five dollars ($125.00) per single contract or three hundred dollars ($300.00) per family per calendar year collectively for well baby care (after the specified limits have been met) and for office visits. The fifteen dollar ($15.00) office visit co-pay shall not be counted toward the $125/300 limits. After deductibles are reached, payment shall then be under the major medical plan; provided, however, that the bill shall be reduced by the fifteen dollar ($15.00) office visit co-pay before the 80%/20% co-payment formula is applied.
(i) The City shall continue to provide a major dental program which provides the following:
Type A Services: Preventative 100%
Type B Services: Major and minor restorative 80%
Type C Services: Orthodontia 60%
Deductible for Type B Services: $50.00 per person per year;
Maximum payment of $1,000.00 per year.
Maximum lifetime benefit for Type C Services for any covered person $1,000.00; coverage limited to dependent children under age 19.
(j) Prescriptive drug program: This program shall continue in effect for the duration of this agreement.
(i) The City shall provide a three tier closed formulary prescriptive drug purchase program with a co-payment structure of a six dollar ($6.00) co-payment for tier 1 drugs (generics), a fifteen dollar ($15.00) co-payment for tier 2 drugs (preferred brand name drugs); and a thirty dollar ($30.00) co-payment for tier 3 drugs (non-preferred brand name drugs). This program will include a generic drug substitution option. The City shall select the provider for the formulary drug program.
(ii) The City may implement managed care for the prescriptive drug program. This would allow for an evaluation of the interaction of an individual's different prescriptions on a voluntary basis.
(k) The coverages described herein shall be under either a single, single plus one or family contract as may be appropriate. The selection of the insurance carrier to provide the coverages herein is the exclusive right of the City.
(l) Monthly contributions will be made by payroll deduction on a pre-tax basis. Spouses who are both employed by the City of Toledo will only pay one (1) premium payment based on the level of coverage selected.