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Your Summary of Benefits anthem. = W. <br />City of South Bend - PPO Plan <br />Blue Access@ (PPO) <br />Effective January 1, 2018 <br />Deductible Sin le/Fami€ <br />$1,0001$3,000 <br />$2,0001$6,000 <br />Out -of -Pocket Limit Sin le/Famil <br />$4,0001$8,000 <br />$7,5001$16,500 <br />Physician Rome and Office Services (PCPISCP) <br />$301$60 <br />40% <br />Primary Care Physician (PCP)l <br />Specialty Care Physician (SCP) <br />Including Office Surgeries and allergy serum: <br />o allergy injections (PCP and SCP) <br />$5 <br />40% <br />o allergy testing <br />20% <br />40% <br />o MRAs, MRIs, PETS, C-Scans, Nuclear <br />20% <br />40% <br />Cardiology Imaging Studies, <br />non -maternity related Ultrasounds, and <br />pharmaceutical products <br />Preventive Care Services <br />Services include but are not limited to: <br />Routine Exams, Mammograms, Pelvic Exams, Pap <br />testing, PSA tests, Immunizations', Annual diabetic eye <br />exam, Vision and Hearing screenings <br />o Physician Home and Office Visits (PCPISCP) <br />NCS <br />40% <br />o Other Outpatient Services @ <br />NCS <br />40% <br />Hospital/Alternative Care Facility_ <br />Emergency and Urgent Care <br />Emergency Room Services <br />$200120% <br />$200120% <br />o facil€tylother covered services <br />(copayment waived if admitted) <br />Urgent Care Center Services <br />$75 <br />40% <br />o MRAs, MRls, PETS, C-Scans, Nuclear <br />20% <br />40% <br />Cardiology Imaging Studies, <br />non -maternity related Ultrasounds, and <br />pharmaceutical products <br />o Allergy injections <br />$5 <br />40% <br />o Allergy testing <br />20% <br />40% <br />Inpatient and Outpatient Professional Services <br />20%- - <br />40% <br />Include, but are not limited to: <br />o Medical Care visits (1 per day), Intensive <br />Medical Care, Concurrent Care, Consultations, <br />Surgery and administration of general <br />anesthesia and Newborn exams <br />Blue 8.0 — -- <br />Anthem Blue Cross and Blue Shield Is the Irado name of Anthem Insurance Companies, Ina Independent licen sea <br />of the Blue Goss and Blua Shfekf Association. ®ANTHEM Is regishrodirademark of Anthem Insane <br />Companies, Inc, The Me Cross and Bhre Shiekl names and symholsate registered marks of the Blue Cross and <br />City of South Bend BA PPO Nallonal PormAoc- Naboat Blue ShfeN Association, <br />