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Your Summary of Benefits <br />City of South Bend - PPO Plan <br />Blue Access® (PPO) <br />Effective January 1, 2019 <br />Deductible (Single/Family) <br />Out -of -Pocket Limit (Single/Family) <br />Physician Home and Office Services (PCP/SCP)��� <br />Primary Care Physician (PCP)/ <br />Specialty Care Physician (SCP) <br />Including Office Surgeries and allergy serum: <br />o allergy injections (PCP and SCP) <br />o allergy testing <br />o MRAs, MRIs, PETS, C-Scans, Nuclear <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 (PCP/SCP) <br />o Other Outpatient Services @ <br />Hospital/Alternative Care Facility <br />Emergency and Urgent Care <br />Emergency Room Services <br />o facility/other covered services <br />(copayment waived if admitted) <br />Urgent Care Center Services <br />o MRAs, MRIs, PETS, C-Scans, Nuclear <br />Cardiology Imaging Studies, <br />non -maternity related Ultrasounds, and <br />pharmaceutical products <br />o Allergy injections <br />o Allergy testing <br />Inpatient and Outpatient Professional Services <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 11.0 <br />$1,000/$3,000 $2,000/$6,000 <br />� <br />_... / <br />$4,000/$8,000 $7,5001$16,500 <br />$301$60 40% <br />$5 40% <br />20% 40% <br />20% 40% <br />NCS 40% <br />NCS 40% <br />$200/20% I $200120% <br />$75 40% <br />20% 40% <br />$5 40% <br />20% 11 J 40% <br />20% 40% <br />At tbam ffim Cow wr� and BNo ONOl1s $0 � ads MUM dtl AnHpmm M ummnce 0.�r%Rn�hm, oac W j ndaaat Wcmnam <br />W'9 W Ceta aftd $I110 ShJ,,OW A vy Won 4 vtlN4': Xdnu oraq�l�9naarah'wul nt aSv�rdX na dn�rormrrn <br />CwipaMurn, lino IN M oCfou and BWknOW rumrmma!mnd np&k, aim regWaod mw k% wow@ 41109 00%and <br />Cttp of South Bond 11b PPO NaHanal Form.doc- Ndanal Blum Shkoki Asrhmmbm,. <br />