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Exhibit A <br /> City of South Bend <br /> 2013 <br /> Health Insurance <br /> Current- New <br /> 2012_= 2013 <br /> Deductible $500 ' $750 <br /> Maximum Family Deductible �_$1,500 $2,250 <br /> Coinsurance 80%_ 80% <br /> Out-of-Pocket Maximum $-7500 $3,000 <br /> Out-of-Pocket Family Max $5,500:; $6,000 <br /> Office Visit Copay PCP $30::.'. $30 <br /> Office Visit Copay Specialist $40 $40 <br /> Urgent Care $50 $50 <br /> Emergency Room 4100+20% $100+20% <br /> Preventive Care Covered a`s any other expense, 100%-No Deductible <br /> Rx-Retail 20%/30%/.40% 20%/30%/40% <br /> Employee Cost Share Per PaylPeriod <br /> Employees Participating in W'ell ess <br /> Y=, <br /> Employee Only $-20 76 $21.80 <br /> Employee&Spouse $54 72 $59.65 <br /> Employee&Child(ren) $41 10' $41.92 <br /> Employee&Family $60 18= $68.61 <br /> Employees Opting Out of Wellness <br /> to ee Only .F Y <br /> p Y Y $45:76 $51.80 <br /> Em <br /> Employee&Spouse $79,72 $89.65 <br /> Employee&Child(ren,) 10> $71.92 <br /> Employee&Family $85 18:' $98.61 <br /> Retiree Cost Share Per Month <br /> Police&Fire Retirees remaining as active union members <br /> Employee Only - %$133 29_ $139.95 <br /> Employee&Spouse $394 83= $430.36 <br /> Employee&Child(ren) 1304,85 $310.95 <br /> Employee&Family $587.65 $669.92 <br /> Police&Fire Retirees-Not remaining as active union members <br /> Employee Only _;$183 29' $189.95 <br /> Employee&Spouse $444.83 $480.36 <br /> Employee&Child(ren) $354.85 - $360.95 <br /> Employee&Family $637.65 $719.92 <br /> Teamster&Non Bargaining Retirees Filed hi ne'' ,'t office <br /> Employee Only $346.00 $401.63 y <br /> Employee&Spouse $912.00 $1,058.63 <br /> Employee&Child(ren) $685.00 $795.13 OCT 2 2 2012 <br /> Employee&Family $1,003.00, $1,164.26 <br /> john wf x�a s 44 <br /> CITY CLERK,SOUTH SEND,IN <br />