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BENEFITS City Health Plan PacificSource Health Plans <br />Administered by ODS Health Plans <br />Rehabilitation <br />(Physical Therapy) <br />80% after deductible if prescribed by <br />physician. <br />Covered in full after $15 co-pay per <br />session; limited to 30 sessions/yr. <br />(combined with Occupational & Speech <br />Therapy). Must be preauthorized. <br />Occupational and 80% after deductible for certain medical Covered in full after $15 co-pay per <br />Speech Therapy conditions if prescribed by physician. session; limited to 30 sessions/yr. <br />(combined with Physical Therapy). <br />Must be preauthorized. <br />Special Provisions <br />Mental Health Benefits provided in accordance with Benefits provided in accordance with <br />Services & Chemical state and federal requirements. state and federal requirements. <br />Dependency <br />including Alcoholism <br />Emergency Care <br />Within Service Area 80% after deductible for treatment of <br />illness; <br />80% with no deductible for treatment of <br />accidental injury. <br />Outside of Service 80% after deductible for treatment of <br />Area illness; <br />80% with no deductible for treatment of <br />accidental injury. <br />Emergency 80% after deductible for local <br />Transportation ambulance service. <br />$100 co-payment per visit; waived if <br />admitted. <br />$100 co-payment per visit; waived if <br />admitted. <br />$50 per trip; waived if admitted. Air <br />ambulance covered when <br />preauthorized. <br />I Other Medical Treatment <br />Alternate Care <br />/ Acupuncture and Chiropractor: 80% <br />after deductible. <br />/ Office visits to Licensed Naturopaths <br />($300 benefit max), Licensed Massage <br />Therapists ($300 benefit max), and <br />Registered Dietitians ($200 benefit <br />max): 80% after deductible. Benefit <br />maximums per calendar year as noted. <br />No limitation on number of visits. <br />Services of Licensed Chiropractors, <br />Licensed Massage Therapists, <br />Registered Acupuncturists & Registered <br />Dieticians; and office visits to Licensed <br />Naturopaths: $15 co-pay per visit, up <br />to 12 visits (12 total visits combined for <br />all types of alternate care providers) <br />per year. <br />Hearing Aids <br />Home Health Care <br />50% of eligible expenses covered after <br />deductible, up to a $500 maximum <br />benefit during a 36-month period. <br />Covered in full after deductible when <br />provided by RN or registered physical <br />therapist and prescribed by a physician. <br />50% of eligible expenses covered up to <br />a $500 maximum benefit during a 36- <br />month period. <br />Covered in full when preauthorized. <br />CITY OF EUGENE: Summary of Benefits for Non-Represented Employees (FY2005) -- Page 4 of 6 <br />