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SUMMARY OF BENEFITS* <br />FO R <br />CITY OF EUGENE AFSCME-REPRESENTED <br />LIMITED DURATION OR BENEFITED TEMPORARY RECREATION EMPLOYEES <br />Effective ]uly 1, 2004 <br />BENEFITS City Health Plan <br /> Administered by ODS Health Plans <br />General Information <br />Benefit Levels The City Health Plan uses the ODS /Providence Vantage Preferred <br /> Provider Organization (PPO) network. Benefit levels after the <br /> deductible: <br /> / In-Network provider: 80% of discounted rates; <br /> / Non-Network provider: 50% of reasonable and customary charges. <br />Service Area Worldwide. Service area for PPO includes all Oregon counties. Also <br /> Pacific, Wahkiakum, Cowlitz, Clark, Skamania, Klickitat, Benton, Walla <br /> Walla Counties in Washington state. <br />Choice of Physician Any qualified physician. While in the service area, you must use a <br /> network provider or hospital to receive in-network benefits. <br />Calendar Year Deductibles $100 per person medical deductible; $300 maximum per family. <br /> $50 per person dental deductible; $150 maximum per family. All <br /> benefits paid after the deductible is met unless otherwise noted. <br />Out-of Pocket Medical Maximums $750 per person each calendar year in addition to the deductible for <br /> covered services. Once this limit has been met, eligible charges are <br /> covered in full for remainder of calendar year. <br />Lifetime Max. Benefit $2,000,000 <br />Pre-existing Conditions for New Benefits limited to $2,000 during the first 6 months for illness or injuries <br />Eligible Employees & Dependents for which you received treatment in the 90 days before coverage <br />(Does not apply to newborn or began. The exclusion period will be reduced by creditable coverage <br />adopted children or pregnancy under another health plan. <br />related conditions) <br />Payroll Deduction Employee-only: $0.00/Pay Period <br /> Employee plus one dependent: $179.21/Pay Period <br /> Em to ee lus two or more de endents: 334.16 Pa Period <br />Eligible Dependents Spouse or domestic partner, and dependent children. <br />*This comparison ofbenefits summarizes the general benefits under each p/an. It does not provide a full <br />description ofbenefits: P/ease contact the individual carriers for further information. <br />CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Limited Duration & <br />Benefited Temporary Recreation Employees (FY2005) -- Page 1 of 4 <br />