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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:

  1. 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;
  2. deductibles to a maximum of $250.00 per person or $500.00 per family per calendar year;
  3. vision hardware as shown below.

Schedule of Benefits

Categories of Expenses  SPRA Reimburses You
Eligible Medical Expenses including:
  • Physician Services
  • Hospital Services
  • Prescriptions
  • Chiropractic Care (10 visits)
  • Ambulance
  • Physical Therapy
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.