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Supplemental Medical Plan D2

Supplemental Medical Plan D2 to City of Seattle's Preventive Plan (or other plan) for Active and Retired Members of SPRA and SPMA

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 your co-pay amounts (shown below) to a maximum of $500.00 per person or $1,000.00 per family per calendar year.

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 $20 co-pay $10 co-pay
Outpatient Mental Health (20 visit limit) $20 co-pay $10 co-pay
Chiropractic Treatment (20 visit limit) $20 co-pay $10 co-pay
Physical Therapy (20 visit limit) $20 co-pay $10 co-pay
Naturopathic Care $20 co-pay $10 co-pay
Chemical Dependency Treatment $20 co-pay $10 co-pay
Physician Office Calls (Out-of-Network): Refer to City's Preventive Plan -0- (not covered)
Urgent Care $35 co-pay $10 co-pay
Emergency Room (waived if admitted) $100 co-pay $10
Prescriptions:
Generic, Name Brand and/or Non-Formulary Up to $15 per co-pay
Mail order, 90-day supply Up to $30 per 90-day co-pay
Vision:
In-Network $10 co-pay $10 co-pay
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
Lifetime Maximum Benefit $50,000.00