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Your Summary of Benefits <br />City of South Bend — HRA Plan <br />Lumenos. Health Reimbursement Accounts <br />Effective January 1, 2018 <br />.em. D®® <br />(W <br />B1ucCross BlueShield e <br />Employer Health Reimbursement Account <br />Contribution: <br />Single: $600 Family., $1,000 <br />Deductible (Embedded) <br />Single: $2,500 <br />Single: $5,000 <br />The single deductible does apply to family coverage. <br />Family: $5,000 <br />Family: $10,000 <br />Employee Bridge Amount* <br />Single: $2,000 <br />Famii : $4,000 <br />Out -of -Pocket Limit <br />Single: $5,000 <br />Single: $10,000 <br />Family: $10,000 <br />family: $20,000 <br />Physician Home and Office Services <br />20% <br />50% <br />o Including Office Surgeries, allergy serum, <br />__ allergy injections and allergy testing <br />Preventive Care Services <br />NCS <br />50% <br />o Routine medical exams, Mammograms, Pelvic <br />Exams, Pap testing, PSA tests, Immunizations, <br />Annual diabetic eye exam, Hearing screenings <br />and Vision screenings which are limited to <br />Screening tests (i.e. Snellen eye chart) and <br />Ocular Photo screening <br />Emergency and Urgent Care <br />o Emergency Room Services Q Hospital <br />20% <br />20% <br />(facilitylother covered services) <br />(copayment waived if admitted) <br />o Urgent Care Center Services <br />20% <br />50% <br />Inpatient and Outpatient Professional Services <br />20% <br />50% <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 />Inpatient Facility Services (Network/Non-Network <br />20% <br />50% <br />combined) Unlimited days except for: <br />0 60 days for physical medicine/rehab <br />(limit includes Day Rehabilitation Therapy <br />Services on an outpatient basis) <br />0 100 days for skilled nursing facility <br />Blue 8.0 <br />Outpatient Surgery Hospital/Alternative Care Facility <br />20%� <br />500 <br />o Surgery and administration of <br />general anesthesia <br />Anthem Blue Cross and Blue Shield N the bade name of Abihem insursno Companies, far, Independent <br />Ifcansee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered kadamarkof Antham <br />Insuranoo Companies, Inc. The Brae Cross and Blue Shield names and symbols amtegistered marks of the Was <br />Oily of South Bend 8.0 LHRA SOB National Form.docKM National Class and Bkto Shield Association. <br />