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BENEFITS City Health Plan PacificSource Health Plans <br />Administered by ODS Health Plans <br />Hospice Care Covered in full after deductible. Covered in full when preauthorized. <br />Podiatrist 80% after deductible. Covered in full after $10 co-pay for non- <br /> routine foot care when preauthorized by <br /> a PCP. <br />Prescription Drugs* Retail (after the deductible): Retail (No claim form required): <br /> Generic: $10 co-payment Formulary: 50% co-payment, <br /> Others: 20% co-payment Non-Formulary: $20 or 50% co-pay, <br /> whichever is greater <br /> Mail Order~Walgreens): Mail-order (Walgreens): <br /> Generic: $10 co-payment Formulary: $15 co-payment <br /> Preferred: $20 co-payment Non-Formulary: $30 co-payment <br /> Premium: $25 co-payment or 25%, <br /> whichever is greater <br /> (with a $50 cap) <br />*See attached information for definitions and list of preferred & premium brands under City P/an. <br />Prosthetic Devices 80% after deductible for devices 80% for initial device replacing body <br />(Pacemaker, artificial replacing body functions. function when obtained while you are <br />limb, etc.) covered by this Plan and when need first <br /> arises. <br />Durable Medical Rental covered at 80% after deductible Covered at 80%. <br />Equipment when prescribed by a physician (up to <br /> the purchase price of rental). <br />Hearing and Vision <br />Hearing Analysis Covered at 80% when prescribed by Routine hearing exams covered in full <br /> physician for medical problems. after $10 co-payment for children under <br /> age 18 once every 24 months when <br /> performed by PCP. <br />Eye Exams 80% with no deductible up to $60 once Covered in full after $10 co-payment for <br /> every 12 months. children under age 18 once every 24 <br /> months. <br /> Adults covered under City Health Plan <br /> vision coverage. <br />CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Employees (FY2005) -- Page 5 of 6 <br />