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
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
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