Supplemental Medical Plan D
Supplemental Medical Plan D to City of Seattle's Preventive Plan (or other plan) for Active and Retired Members of SPRA and SPOG
The purpose of the Plan is to promote the health and welfare of all covered persons through supplemental medical and prescription drug benefits. The Plan reimburses co-pay amounts to a maximum of $500.00 per person or $1,000.00 per family per calendar year. The calendar year is January through December. Note: Vision hardware benefit is separate from the $500 plan maximum.
Schedule of Benefits
| Categories of Expenses | Under the City's Preventive Plan (or other plan) You Pay | SPRA Reimburses You |
| Physician Office Calls (In-Network): | ||
| Illness, accident, and preventive care | $5 co-pay | $5 co-pay |
| Outpatient Mental Health (20 visit limit) | $5 co-pay | $5 co-pay |
| Chiropractic Treatment (20 visit limit) | $5 co-pay | $5 co-pay |
| Physical Therapy (20 visit limit) | $5 co-pay | $5 co-pay |
| Naturopathic Care | $5 co-pay | $5 co-pay |
| Chemical Dependency Treatment | $5 co-pay | $5 co-pay |
| Physician Office Calls (Out-of-Network): | Refer to City's Preventive Plan | -0- (not covered) |
| Urgent Care | $35 co-pay | $10 |
| Emergency Room (waived if admitted) | $50 co-pay | $10 |
| Prescriptions: | ||
| Generic, Brand Name, and/or Non-formulary | Up to $15 per co-pay | |
| Mail order, 90-day supply | Up to $30 per 90-day supply | |
| Vision: | ||
| Glasses (Lenses and/or frames ) | Up to $50 per year | |
| Contact Lenses | Up to $40 per year | |
| Annual Out-of-Pocket Maximum: | ||
| Per Individual | $500 | $500 |
| Per Family | $1,000 | $1,000 |