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BENEFITS City Health Plan PacificSource Health Plans <br />Administered by ODS Health Plans <br />Prescription Lenses Lenses and frames or cosmetic contacts Covered under City Health Plan vision <br /> covered once every 24 months with coverage. <br /> examination. <br /> Frames $50 <br /> Single lens $20 per lens <br /> Bifocals $30 per lens <br /> Cosmetic Contacts $70 (both lenses) <br /> $60 per lens for contacts required after <br /> cataract surgery or if vision cannot be <br /> corrected to 20/70 without such lenses. <br /> Covered once every 24 months. <br />Dental* <br />Preventive Dental 100% no deductible. Covered under City Health Plan dental <br />Care-Exams, Bite- coverage. <br />Wing X-Rays, <br />Fluoride, and <br />Routine Cleaning <br />Fillings, Restorative 80% after $50 deductible. Covered under City Health Plan dental <br />Crowns, Denture coverage. <br />Repairs <br />Initial and 50% after $50 deductible. Covered only Covered under City Health Plan dental <br />Replacement if previous denture or bridgework is coverage. <br />Dentures and more than five years old, and teeth. <br />Bridgework were removed while the covered person <br /> was eligible for coverage under this <br /> plan. <br />Orthodontia 50% with no deductible. $2,000 lifetime Covered under City Health Plan dental <br /> maximum per covered person. coverage. <br />Maximums First calendar year of coverage: $250. First calendar year of coverage: $250. <br /> Each succeeding calendar year: $1,250. Each succeeding calendar year: $1,250. <br />*Citys denta/ p/an uti/izes participating dentists who have contracts with ODS. Benefit leve/s for <br />non participating denta/providers are based on the prevailing fee level for covered services. <br />For a list of exclusions under your plan, contact the individual carrier or call Human Resource and Risk Services <br />at (541) 682-5061. <br />CITY OF EUGENE: Summary of Benefits for AFSCME-Represented Employees (FY2005) -- Page 6 of 6 <br />