Supplemental Medical Plan C
The purpose of this Plan is to promote the health and welfare of all covered persons through supplemental medical, prescription drug, and vision benefits. The Plan reimburses:
- co-insurance and prescription expenses for which you are responsible under your primary insurance plan, to a maximum of $750.00 per person per calendar year;
- deductibles to a maximum of $250.00 per person or $500.00 per family per calendar year;
- vision hardware as shown below.
Schedule of Benefits
Categories of Expenses | SPRA Reimburses You |
Eligible Medical Expenses including: | |
|
Remaining 20% of Eligible Medical Expenses not paid under your primary individual or group insurance plan up to $750.00 per person per calendar year |
Mental Health Expenses | 2-day lifetime maximum, inpatient only |
Chemical Dependency only | $2,000.00 lifetime maximum; inpatient only |
Medical Deductible | Actual deductible paid, not to exceed $250.00 per person or $750.00 per family per calendar year |
Vision Expenses: | |
Single Vision Lenses | $20.00 per lens per calendar year |
Bifocals | $30.00 per lens per calendar year |
Trifocals | $40.00 per lens per calendar year |
Lenticular | $65.00 per lens per calendar year |
Contacts | $20.00 per lens per calendar year |
Aphakia & correction to 20/70 | $100.00 per lens per calendar year |
Frames | $30.00 every two calendar years |
Lifetime Maximum Benefit | $50,000.00 |
Note: All vision, inpatient mental health, and chemical dependency expenses and deductible reimbursements are not included in the $750.00 medical expense limit described above.