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BENEFITS City Health Plan <br />Administered by ODS Health Plans <br />Dependent Children In addition to other policy requirements, unmarried, dependent children <br />under age 19; or under age 23 if a full-time student in an accredited <br />school. Students must be enrolled for 12 or more class hours per week. <br />Claims Filing ID card provided. Claim forms may be submitted by either the patient <br />or the provider. <br />For More Information ODS Health Plans Portland Office: (800) 575-9295 <br />Human Resource & Risk Services: (541) 682-5061 <br />Note: Benefits described below assume plan members receive services through the City Health <br />Plan PPO. <br />Hospital Services <br />Semi-private Room and Board 80% after deductible up to average semi-private room rate of <br />$891/day. (Intensive care room rate 3 times semi-private rate.)* <br />*Subject to comp/lance with uti/ization review. Rate adjusted annua//y. <br />Maternity Care <br />Hospital Services including <br />Caesarean Sections and <br />Newborn Care Covered the same as any other medical condition; routine hospital <br />nursery care covered from date of birth; 100% after deductible for <br />delivery at licensed birthing center <br />Physician Hospital Services <br />including Prenatal, Delivery and <br />Postnatal Care of Mother & Child 80% after deductible. <br />Physician Services <br />Office Visits 80% after deductible; <br />80% no deductible for treatment of accidental injury. <br />Allergy Injections 80% after deductible. <br />Hospital Visits 80% after deductible. <br />Surgery/Delivery <br /> Inpatient 80% after deductible. <br /> Outpatient 100% no deductible. <br />Preventive and Well-Care Services <br />Periodic Physical Exams <br />(eligibility by age) Covered at 80% to a maximum benefit of $250; no deductible. <br />Well-Baby/Child Care Covered at 80% du ring first 24 months, no deductible. <br />Immunizations Covered at 80% for adults and children; no deductible. <br />Breast, Pap and Pelvic Exams, <br />Mammography Covered at 80% once every 12 months, no deductible. <br />CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Limited Duration & <br />Benefited Temporary Recreation Employees (FY2005) -- Page 2 of 4 <br />