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.........__ <br />BENEFITS City Health Plan PacificSource Health Plans <br />Administered by ODS Health Plans <br />Pre-existing Conditions <br /> Open enrollment If you have been enrolled for 6 consecutive months in one of the City's health <br /> plans, you may transfer at open enrollment without any pre-existing condition <br /> limitations. <br /> New Eligible Benefits limited to $2,000 during the No pre-existing condition limitations <br /> Employees & first 6 months for illness or injuries for under PacificSource Health Plans. <br /> Dependents which you received treatment in the 90 <br /> (Does not apply days before coverage began. The <br /> to newborn or exclusion period will be reduced by <br /> adopted children creditable coverage under another <br /> or pregnancy health plan. <br /> related <br /> conditions) <br />Eligible Dependents Spouse or domestic partner, and Spouse or domestic partner, and <br /> dependent children. dependent children. <br />Dependent Children In addition to other policy requirements, In addition to other policy requirements, <br /> unmarried, dependent children under unmarried, dependent children under <br /> age 19; or under age 23 if a full-time age 19, or under age 23 if they are full- <br /> student in an accredited school. time students (as defined by the policy). <br /> Students must be enrolled for 12 or <br /> more class hours per week. <br />Payroll Deduction AFSCME-Represented employees working at least 32 hours per week or more do <br /> not have a payroll deduction for their health insurance coverage. However in <br /> FY2004, all AFSCME-represented employees contribute 20% of the health insurance <br /> premium cost increase over the prior year's cost, up to a maximum of .5% of <br /> sala See current AFSCME Contract Article 22.3 for more information. <br />Claims Filing ID card provided. Claim forms may be ID card provided. No claim forms <br /> submitted by either the patient or the needed for PacificSource. <br /> provider. <br />For more ODS Health Plans Portland Office: PacificSource Customer Service: <br />Information (800) 575-9295 (541) 684-5582 or <br /> Human Resource & Risk Services: (888) 977-9299 <br /> (541) 682-5061 www.pacificsource.com <br />Note: Benefits described below for the health plan options assume plan members receive <br />services preauthorized by their PacificSource PCP or through the City Plan PPO. <br />Hospita I Services <br />Semi-private Room 80% after deductible up to average Paid in full after $50 copayment per day <br />and Board semi-private room rate of $891/day. ($250 maximum per stay). <br /> (Intensive care room rate 3 times semi- <br /> private rate.)* <br />*Subject to comp/lance with uti/ization review. Rate adjusted annua//y. <br />CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Employees (FY2005) -- Page 2 of 6 <br />