Medical Plan - Aetna Health HMO

October 1, 2003 - September 30, 2004

Information provided is in summary format.  Any difference between the summary provided and actual contract will be settled in favor of the contract.

Network

Aetna Providers*

Deductible

None

Coinsurance**

90%

Out-of-Pocket Max

$1,500 Individual/$3,000 Family

Maximum Benefit

Unlimited

Office Visits

$15 Copay, then 100%

Preventive Care

$15 Copay, then 100%

Lab Work

$20 Copay

Ambulance

100%

Hospital Inpatient***

$100 Copay

Emergency Room

$50 Copay (waived if admitted)

Chiropractic - 20 visits/yr

$20 Copay

Rehabilitation:

     Inpatient***- 120 days/yr

$50 Copay/day

     Outpatient

$20 Copay

Mental Nervous:

     Inpatient***- 30 days/yr

$100 Copay

     Outpatient - 30 visits/yr

$25 Copay

Chemical Dependency:

$11,285 max in 24 month period

     Inpatient***

$100 Copay

     Outpatient

$20 Copay

$20 Copay
See the self-funded NBN Vision Plan Summary offered by the Seattle Public Schools to all eligible employees.

$20 Copay

Retail Prescriptions

(Par Pharmacies)

Generic:  $10 Copay

Preferred Brand:  $20 Copay

Non-Preferred Brand:  $35 Copay

30-day supply

Generic:  $20 Copay

Preferred Brand:  $40 Copay

Non-Preferred Brand:  $70 Copay

90-day supply

*No benefits are payable for services outside of the Aetna Managed Care Network unless it is a medical emergency.  Also, referrals are generally required from your Primary Care Provider (PCP) for care outside your PCP.

**Of allowable charges

***Pre-authorization is required for inpatient hospitalizations outside plan service area.