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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 <br />Employees & <br />Dependents <br />(Does not apply <br />to newborn or <br />adopted children <br />or pregnancy <br />related <br />conditions) <br />Benefits limited to $2,000 during the <br />first 6 months for illness or injuries for <br />which you received treatment in the 90 <br />days before coverage began. The <br />exclusion period will be reduced by <br />creditable coverage under another <br />health plan. <br />No pre-existing condition limitations <br />under PacificSource Health Plans. <br />Eligible Dependents <br />Dependent Children <br />Payroll Deduction <br />Claims Filing <br />Spouse or domestic partner, and Spouse or domestic partner, and <br />dependent children. dependent children. <br />In addition to other policy requirements, <br />unmarried, dependent children under <br />age 19; or under age 23 if a full-time <br />student in an accredited school. <br />Students must be enrolled for 12 or <br />more class hours per week. <br />In addition to other policy requirements, <br />unmarried, dependent children under <br />age 19, or under age 23 if they are full- <br />time students (as defined by the policy). <br />Non-Represented Full-time Employees <br />(working 32 hours/week or more): <br />Individual: $15.90/Pay Period <br />Two-Party: $29.38/Pay Period <br />Family: $41.05/Pay Period <br />ID card provided. Claim forms may be <br />submitted by either the patient or the <br />provider. <br />For more ODS Health Plans Portland Office: <br />Information (800) 575-9295 <br />Human Resource & Risk Services: <br />(541) 682-5061 <br />Non-Represented Full-time Employees <br />(working 32 hours/week or more): <br />Individual: $11.23/Pay Period <br />Two-Party: $22.60/Pay Period <br />Family: $33.01/Pay Period <br />ID card provided. No claim forms <br />needed for PacificSource. <br />PacificSource Customer Service: <br />(541) 684-5582 or <br />(888) 977-9299 <br />www. pacificsou rce. 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* <br />and Board <br />to comp/lance with uti/ization review. <br />Paid in full after $100 co-payment per <br />day ($500 maximum per stay). <br />CITY OF EUGENE: Summary of Benefits for Non-Represented Employees (FY2005) -- Page 2 of 6 <br />