Accidental injury — A bodily injury to a covered person that is caused solely by external, violent and accidental means and results directly in a covered expense, independently of other causes. Intentionally self-inflicted injuries are not covered.

Brand name drug — A drug marketed under a trademark name, usually created by the manufacturer that holds the patent on the drug. A brand name drug cannot be distributed by another manufacturer (for example, as a generic drug) until the patent expires.

Calendar year — Each year, January 1 through December 31.

Chemical dependency (under the mental health and chemical dependency benefit) — An addictive relationship with alcohol or any drug, excluding tobacco products. The dependency may be physical or psychological or both. It must interfere with a person's social, psychological or physical adjustment. Food addictions are not considered chemical dependency.

Claims administrator — Trust Office.

Collective bargaining agreement — A collectively bargained agreement between the District and a labor organization that requires contributions to the Trust.

Contracted rate — For Providence and MultiPlan preferred providers, the contracted rate is based on a negotiated fee for services rather than billed charges. The use of a contracted rate rather than actual billed charges can result in you paying a different amount under the plan.

Contribution — The amount paid to the Trust by the District or a participating employee, by payroll deduction or otherwise, to provide benefits for participating employees and their dependents.

Copayment — The dollar amount you must pay upon receipt of services or supplies covered by the plan.

Cosmetic procedures — Procedures (including surgery) that are not medically necessary and are primarily for the enhancement of physical appearance or self-esteem. Cosmetic procedures may be covered only if used to correct functional disorders or repair damage resulting from an accidental injury, or for breast reconstruction (of either breast) following a mastectomy or lumpectomy, if medically necessary.

Covered expenses — Usual and customary or reasonable charges for services and supplies that are medically necessary for diagnosis and treatment of an illness or injury and for which benefits are provided by the plan.

Covered person — An employee of the District or a dependent of the employee who meets the plan's eligibility and enrollment requirements.

Covered services— Services or supplies for which benefits are provided by this plan, subject to the plan's conditions and limitations.

Custodial care — Care that helps a person conduct activities of daily living and that can be provided by people without medical or paramedical skills. Custodial care also includes care primarily for separating a patient from others or preventing a patient from harming him/herself.

Deductible — The portion of covered expenses a covered person must pay each year before the plan pays benefits.

Dentist — A doctor of medical dentistry or dental surgery (DMD or DDS) acting within the scope of his or her license to treat accidental injury to natural teeth or a fractured jaw, or to perform surgery (such as surgical treatment of tumors of the mouth) that does not involve repair, removal or replacement of teeth, gums or supporting tissue.

Dependent — The spouse or domestic partner of a covered employee or any unmarried child of the employee, spouse or domestic partner who meets the plan's eligibility requirements.

District — School District No. 1, Multnomah County, Oregon.

Eligible provider — Any of the following who provide medically necessary services within the scope of his or her license:

Emergency — A medical condition that could be life-threatening or have serious long-term or permanent effects if not treated as soon as possible. Loss of consciousness, uncontrolled bleeding, chest pain or other severe pain, or difficulty breathing are examples of medical emergencies. A psychiatric emergency exists when a person is in immediate danger of harming himself or herself or others.

Emergency admission (under the mental health and chemical dependency benefit) — A covered person's admission to a health care, residential, partial hospitalization or day care facility because the person's condition due to mental illness or chemical dependency constitutes a threat of immediate harm to his or her health.

Employee — Any person employed by School District No. 1, Multnomah County, Oregon, who is eligible to participate in the plan.

Experimental and investigational drugs — Unapproved medications still going through the FDA (Food and Drug Administration) approval process.

Generic drug — A drug that is chemically and therapeutically equivalent to a brand name drug whose patent has expired. Generic drugs are typically less expensive than their brand name counterparts and are sold under the drugs' common names.

Home health care — Care provided through a qualified, licensed or certified home health care agency or program to provide medical support services in a patient's home.

Hospice facility — A licensed facility primarily engaged in providing care, counseling and incidental medical services to terminally ill patients with a life expectancy of six or less months and to the patient's immediate family.

Hospital — A facility that provides diagnostic and therapeutic facilities for inpatient medical and surgical treatment of persons who are ill or injured. It must be licensed under applicable laws as a general hospital by the state in which treatment is provided, accredited by the Joint Commission on Accreditation of Hospitals or approved by Medicare as a hospital. Its services must be supervised by a staff of physicians and must include 24-hour-a-day nursing services by registered nurses or other nursing staff under the supervision of a registered nurse. It must be operated continuously with organized facilities for surgery on the premises.

Facilities that are primarily for rest, old age or custodial care are not considered hospitals. Similarly, facilities for the treatment of chemical dependency (including alcoholism) and mental disorders are not considered hospitals. This includes facilities within hospitals that may be used for such treatment.

Illness — A physical or mental disorder that results in a covered expense. A physical disorder is a disease or bodily disorder. A mental disorder is a psychological condition characterized by psychological pain or distress and substantial impairment of basic functioning. Under this plan, illness also includes:

Inpatient treatment (under the mental health and chemical dependency benefit) —Treatment in a hospital or other facility licensed to provide care under state law or accredited by the Joint Commission on Accreditation of Hospitals or the Commission on the Accreditation of Rehabilitation Facilities. The facility must be licensed to admit patients who require 24-hour skilled nursing care and must provide full-day or partial-day treatment for mental illness, acute alcoholism or drug addiction.

Licensed clinical social worker — A person who specializes in clinical social work and is licensed or certified as a social worker by the appropriate authority.

Maintenance prescription drug — Drugs taken on a long-term basis to treat chronic illnesses or conditions such as high blood pressure, diabetes or asthma.

Medically necessary — Those services and supplies which are required for diagnosis or treatment of illness or injury. Medically necessary services and supplies must be:

Medically necessary services do not include maintenance, custodial or palliative treatment or services. The fact that a professional provider may prescribe, order, recommend or approve a particular service or supply does not, of itself, make the charge a medically necessary covered expense.

Medicare — The Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act.

Mental or nervous disorder (under the mental health and chemical dependency benefit) — A psychological disorder characterized by psychological pain or distress and substantial impairment of basic functioning, including psychoneurosis, psychopathy, psychosis and mental or emotional disorder or disease of any kind.

Nonparticipating pharmacy — A retail pharmacy not participating in the CVS Caremark retail pharmacy network.

Nonpreferred providers — Under this plan, providers who are not part of the Providence Preferred provider network (for Full-Time/Part-Time Option 1 Trust Preferred Provider Plan or Part-Time Option 2 Trust Indemnity Medical Plan) or MultiPlan provider network (for Full-Time/Part-Time Option 1 Trust Preferred Provider Plan MultiPlan) as selected prior to the plan year.

Non-VSP provider — Any optometrist, optician, ophthalmologist or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to covered persons of VSP.

Nurse practitioner — A person certified to practice as a nurse practitioner who:

Option 1 — The Trust Plan for eligible full-time and part-time employees and their eligible dependents (part-time employees have a choice of Option 1 or Option 2). Option 1 includes medical, prescription drug, dental, vision, disability, life and survivor benefits.

Option 2 — The Trust Plan for eligible part-time employees and their eligible dependents (part-time employees have a choice of Full-Time/Part-Time Option 1 or Part-Time Option 2). Part-Time Option 2 includes medical and prescription drug benefits.

Out-of-pocket maximum — The maximum amount a covered person will need to pay out-of-pocket for covered expenses within a calendar year.

Outpatient program — A program of medical care and treatment that:

Outpatient treatment (under the mental health and chemical dependency benefit) —Treatment through a program that meets the standards of the Oregon Mental Health Division or the Oregon Office of Drug and Alcohol Abuse Programs (or equivalent agency if services are provided in another state). Treatment must be provided by one of the following:

Participating pharmacy — A retail pharmacy participating in the CVS Caremark retail pharmacy network.

Pharmacist — A person who is licensed to prepare and dispense drugs.

Person eligible under Medicare — A covered person who is entitled to enroll in and be covered under the voluntary portion of Medicare.

Plan — The School District No. 1 Health and Welfare Trust Group Medical Plan (the Trust Indemnity Medical Plan and Trust Preferred Provider Plan) described in this document.

Plan — The School District No. 1 Health and Welfare Trust Prescription Drug Plan described in this document

Plan (from Vision) — The School District No. 1 Health and Welfare Trust Vision Plan described in this document.

Plan (from Dental) — The School District No. 1 Health and Welfare Trust Dental Plan described in this document.

Plan administrator — The administrator retained by the Board of Trustees to administer the plan under the Board's direction and control. Administrative duties include (but are not limited to) maintaining eligibility records and processing claims.

Plan document — The written Trust Indemnity Medical Plan and Trust Preferred Provider Plan document.

Plan document (from Prescription Drugs) — The written Trust Prescription Drug Plan document.

Plan document (from Vision) — The written Trust Vision Plan document.

Plan document (from Dental) — The written Trust Dental Plan document.

Plan year — February 1 to January 31.

Portland Association of Teachers (PAT) — The collective bargaining agreement you work under that governs your eligibility to participate in the Trust. (See Participating in the Plans — Eligibility for details).

Preauthorization — Prior authorization needed from the prescribing physician before certain prescriptions will be filled by a retail pharmacy or the mail order service. Preauthorization may be required due to the specific drug, the supply size or dosage, or the timing of the prescription or refill.

Preferred provider — Doctors and hospitals who have contracted with a preferred provider organization (PPO) and agreed to accept preferred payment rates for eligible persons. For Full-Time/Part-Time Option 1 and Part Time Option 2 Trust Preferred Provider Plan, the preferred provider network is either Providence Preferred or MultiPlan, depending on which network was chosen by the employee prior to the plan year.

Preferred provider organization (PPO) — A group of health care providers who have agreed to offer services and supplies at contracted rates.

Prescription — A written order for dispensing and administering a drug, signed by a professional provider who is licensed to prescribe drugs.

Prescription drugs — Medicines, drugs or supplies that are used for the treatment of illness or injury and cannot be legally dispensed without a written prescription.

Professional provider — Any of the following who provides medically necessary services within the scope of his or her license:

Psychologist — A person who specializes in clinical psychology and who is:

Reconstructive surgery — Surgery to repair damage due to an accidental injury or amputation, including reconstructive surgery on one or both breasts following a mastectomy or a lumpectomy, if medically necessary.

Refill — The continuation of an original prescription, as authorized by the prescribing professional provider.

Residential, partial hospitalization or day care facility (under the mental health and chemical dependency benefit) — A residential facility, hospital or other facility that provides an organized full-day or partial-day treatment program for chemical dependency (including alcoholism) or mental/nervous disorders. The facility must be licensed under state law or accredited by the Oregon Mental Health Division or the Oregon Office of Drug and Alcohol Abuse Programs (or equivalent agency if services are provided in another state) to provide the level of care for which benefits are claimed.

Room and board — Room, board, general duty nursing, intensive nursing care and any other charges for services regularly provided by a hospital for the class of accommodations occupied. Room and board does not include professional services of physicians or special nursing services provided outside an intensive care unit.

Services and supplies — Services and supplies for which coverage is provided by this plan that are required for treatment of a medical condition and which are furnished to a covered person. Services and supplies does not include the professional services of any physician and any private duty or special nursing services including intensive nursing care by whatever name called.

Skilled nursing facility — Any of the following:

Facilities approved by Medicare as skilled nursing facilities are covered by the plan. If not approved by Medicare, a facility may be covered if it:

Total disability/totally disabled — A covered employee's complete inability to perform the principal duties of his or her occupation, or a dependent's complete inability to perform the normal activities of a person of like age and gender.

Treatment center (under the mental health and chemical dependency benefit) — Centers that provide a program of effective medical and therapeutic treatment of chemical dependency (including alcoholism). Some states have laws requiring group insurance plans to cover such centers. In those states, this plan covers treatment centers that are licensed by the state. In other states, a treatment center may be covered if it:

A treatment center that qualifies as a hospital under this plan is covered as a hospital, not treatment center.

Trust — The School District No. 1 Health and Welfare Trust.

Trust agreement — The Trust Agreement of the School District No. 1 Health and Welfare Trust Fund and any valid amendments.

UCR — Usual and customary or reasonable charges.

For Providence and MultiPlan preferred providers, the UCR rate may be based on a contracted fee for services rather than billed charges. The use of a contracted rate rather than actual billed charges can result in your paying a different copayment under the plan.

Usual and customary or reasonable (UCR) rates (from Dental) — The fees and prices regularly charged by your dentist and other dentists in your area for the dental services and supplies generally furnished for cases like yours.

Usual and customary or reasonable (UCR) rates (from Vision) — The rates charged for a given vision service or supply by similar providers in your geographic area.

VSP preferred provider — An optometrist or ophthalmologist licensed and qualified to practice vision care and/or provide eyewear who has contracted with VSP to provide vision care services and/or eyewear to VSP members.

Visually necessary or appropriate — Services and materials medically or visually necessary to restore or maintain a patient's visual acuity and health and for which there is no less expensive professionally acceptable alternative, as determined by VSP.