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 | |