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					                                                                                   Confidential
                                                                               Salem-Keizer SD 24J
                                                                                Med Plan 1               Med Plan 5                Med Plan 7                Med Plan 8
Medical Plans                                                                  Kaiser HMO                ODS PPO                   ODS PPO                   ODS PPO
Lifetime Benefit Maximum                                                         Unlimited                Unlimited                 Unlimited                 Unlimited
Deductible
  In Network (Individual/Family)                                                None/None                $200/$600                $500/$1,500              $1,000/$3,000
 Out of Network (Individual/Family)                                                 N/A            Combined in/out network   Combined in/out network   Combined in/out network
Maximum out-of-pocket costs per plan year
  In Network (Individual/Family)                                               $1,200/$2,400          $1,800 per person         $2,000 per person         $2,000 per person
  Out of Network                                                             See EOC for detail       $3,600 per person         $4,000 per person         $4,000 per person
After the maximum out-of-pocket costs have been paid, the plan will
pay, except for Specialty/Shared Cost tier                                         100%                      100%                     100%                     100%
Preventive Care Services                                                 $ and % shown is the Member Cost;    $ Amounts = Copayment
Adult,Well-child,Well-baby exams (in network/out of network)                        $0                    0%*/40%                   0%*/40%                   0%*/40%
Immunizations (In network/Out Network)                                             $0/NA                  0%*/40%                   0%*/40%                   0%*/40%
Preventive Care Svcs as described in Plan Handbook                                 $0/NA                  0%*/40%                   0%*/40%                   0%*/40%
Provider Services (In Network/Out of Network)                                                       * Deductible Waived       * Deductible Waived       * Deductible Waived
Incentive Office Visits for asthma, heart conditions (CHF, Cholesterol
& High BP) & Diabetes Management                                                    NA                    $10*/40%                  20%/40%                   20%/40%
Primary Care Services as described in Plan Handbook                               $10/NA                  $25*/40%                  20%/40%                   20%/40%
Specialist Office Visit                                                           $15/NA                  $25*/40%                  20%/40%                   20%/40%
Specialty/Shared Cost Tier                                                          NA             $500 + 20%/$500 + 40%     $500 + 20%/$500 + 40%     $500 + 20%/$500 + 40%
Imaging Services                                                                   $0/NA           $100 + 20%/$100 + 40%     $100 + 20%/$100 + 40%     $100 + 20%/$100 + 40%
Weight Loss Mgmt (benefit for employee only)                                                        * Deductible Waived
4-13 Week Weight Management Sessions/Year                                       No Charge                No Charge                 No Charge                 No Charge
Urgent Care                                                                                         * Deductible Waived
Urgent Care Visit                                                                   $10                       $25*                     20%                      20%
Alternative Care (In Network/Out of Network)**                                                      * Deductible Waived
Acupuncture, Chiropractic, Naturopathic Services                                  $10/NA                  $25*/40%                  20%/40%                   20%/40%
 **$2,000 Maximum Combined Benefits
Pharmacy Services                                                        $ and % shown is the Member Cost;    $ Amounts = Copayment
                                                                              Kaiser Rx Plan          ODS Rx Option B           ODS Rx Option B           ODS Rx Option B
Out of Pocket Maximum                                                             $1,000                     $1,000                   $1,000                  $1,000
Retail                                                                     (up to 30 day supply)    (up to 31 day supply)     (up to 31 day supply)     (up to 31 day supply)
  Value                                                                             NA                        $4                       $4                        $4
  Generic                                                                           $5                        $8                       $8                        $8
  Preferred                                                                         $25                       $25                      $25                      $25
  Non-Preferred                                                              $25 if criteria met              50%                      50%                      50%
Mail                                                                       (up to 90 day supply)    (up to 90 day supply)     (up to 90 day supply)     (up to 90 day supply)
  Value                                                                             NA                        $8                       $8                        $8
  Generic                                                                           $10                       $16                      $16                      $16
  Preferred                                                                         $50                       $50                      $50                      $50
  Non-Preferred                                                              $50 if criteria met      50% ($100 max)            50% ($100 max)            50% ($100 max)
                      Plan Option                          Dental Plan 1         Dental Plan 8                Plan Option      Vision Plan 3          Vision Plan 5
Dental                                                         ODS                   Kaiser             Vision                     ODS                   Kaiser
Deductible                                                     $50                   None               Plan Year Maximum          $450             See allowances

Dental Office Visit                                             NA          $20 applies at each visit   Routine Eye Exam           100%            100% up to $64.50
Plan Year Maximum                                             $2,200                 None               Exam Frequency       Once per plan year   Once per 12 months
Preventive and Diagnostic Services                     *Deductible Waived                               Lenses                 Either one pair of lenses or contacts
Oral exams, X-rays, cleaning (prophylaxis),               *70% + 10%
fluoride treatments, space maintainers                   each plan year             **100%               Single Vision             100%            100% up to $58.50
Restorative Services                                                                                     Bifocal                   100%            100% up to $86.00
                                                           70% + 10%
Routine fillings and stainless steel crowns               each plan year            **100%               Lenticular                100%            100% up to $86.00
Simple Extraction                                                                                        Trifocal                  100%           100% up to $109.00
                                                           70% + 10%
Simple Tooth Extractions                                  each plan year            **100%               Contact Lenses            100%           100% up to $192.50
Oral Surgery                                                                                            Lens Frequency      Once per plan year    Once per 12 months
Surgical tooth extractions, including diagnosis            70% + 10%
and evaluation                                            each plan year            **100%              Frames                     100%            100% up to $75.00
Peridontics                                                                                             Frame Frequency     Child:once/plan year Child:once/12 months
Diagnosis, evaluation, and treatment of gum                70% + 10%                                                        Adult: once every two Adult: once every 24
disease including scaling and root planing                each plan year            **100%                                        plan years             months
Endodontics
Root canal and related therapy including                   70% + 10%
diagnosis and evaluation                                  each plan year            **100%
Major Restorative Services
                                                           70% + 10%
Gold or porcelain crowns and inlays                       each plan year            **100%
                                                           70% + 10%
Implants                                                  each plan year            **100%              This is a basic summary only. Full plan descriptions are
Fixed and Removable Prosthetic Services                                                                 available on oebb.benefits@state.or.us or you may
                                                           70% + 10%                                    contact the Benefits Office (503-399-5556) for a hard
Full and partial dentures, relines, rebases               each plan year            **100%              copy of the Plan Handbook.
                                                           70% + 10%
Bridge retainers and pontics                              each plan year            **100%
Orthodontics                                                                    Ortho Option 2
                                                          80% to $1,500         $1,500 copay +
Orthodontics                                               lifetime max          $10 per visit
**Office visit copay applies at each visit in addition to any copayments