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BENEFITS City Health Plan PacificSource Health Plans Administered by ODS Health Plans Maternity Care Hospital Services Covered the same as any other medical Covered in full for outpatient delivery. including Caesarean condition; routine hospital nursery care Inpatient delivery covered in full after Sections and covered from date of birth; 100% after $50 copayment per day ($250 maximum Newborn Care deductible for delivery at licensed per stay). birthing center Physician Hospital 80% after deductible. Covered in full after $25 co-payment per Services including pregnancy. Prenatal, Delivery and Postnatal Care of Mother and Child Physician Services Office Visits 80% after deductible; 80% no Covered in full after $10 co-payment per deductible for treatment of accidental visit. injury. Allergy Injections 80% after deductible. Covered in full. Hospital Visits 80% after deductible. Covered in full. Surgery/Delivery Inpatient 80% after deductible. Covered in full. Outpatient 100% no deductible. Surgery covered in full. $10 office visit copayment if performed in physician's office. Preventive and Well-Care Services Periodic Physical Covered at 80% to a maximum benefit Covered in full after $10 co-payment per Exams (eligibility by of $250; no deductible. visit. age) Well-Baby/Child Care Covered at 80% during first 24 months, Covered in full after $10 co-payment per no deductible. -visit (subject to schedule). Immunizations Covered at 80% for adults and children; Covered in full. no deductible. Breast, Pap and Covered at 80% once every 12 months, Covered in full after $10 co-payment Pelvic Exams, no deductible. (one per calendar year). Mammography Mammography subject to schedule of eligibility. Outpatient Services X-Ray, Lab Tests and 80% after deductible for illness; 80% no Covered in full. Radiation Therapy deductible for treatment of accidental injury. CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Employees (FY2005) -- Page 3 of 6