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Exhibit A <br /> City of South Bend <br /> 2013 <br /> Health Insurance <br /> Current _- New <br /> Y 201h2= 2013 <br /> Deductible $50© $750 <br /> Maximum Family Deductible $1,500. $2,250 <br /> Coinsurance $0/0 80% <br /> Out-of-Pocket Maximum $2.500 $3,000 <br /> Out-of-Pocket Family Max $5.5001 $6,000 <br /> Office Visit Copay PCP 30 $30 <br /> Office Visit Copay Specialist _ $ 0 $40 <br /> Urgent Care $50 R' $50 <br /> Emergency Room $;100+20% ;° ' $100+20% <br /> Preventive Care Covered fas any other expense 100%-No Deductible <br /> Rx-Retail 20%/330%-0/{00% 20%/30%/40% <br /> Employee Cost Share Per Pay Period <br /> i <br /> Employees Participating in Wellness A 5 ,� <br /> Employee Only 5 4 -$200.7 $21.80 <br /> Employee&Spouse $54"72 $59.65 <br /> Employee&Child(ren) . 41.10 $41.92 <br /> Employee&Family <-_,$ ,0.1 ,...,'° $68.61 <br /> Employees Opting Out of Wellness <br /> Employee Only $45.76 $51.80 <br /> Employee&Spouse T9.72 f, $89.65 <br /> Employee&Child(ren) k $6610 $71.92 <br /> Employee&Family ;' $85.1 $98.61 <br /> Retiree Cost Share Per Month <br /> Police&Fire Retirees remaining as active union members <br /> Employee Only 14 $1332 $139.95 <br /> Employee&Spouse , - $394. 3 $430.36 <br /> Employee&Child(ren) N -$304.85 $310.95 <br /> Employee&Family " �,4 _ $587.65 $669.92 <br /> Police&Fire Retirees-Not remaining as active union members <br /> Employee Only ±083 29 $189.95 <br /> Employee&Spouse '$444.83 $480.36 <br /> Employee&Child(ren) $354`85 $360.95 <br /> Employee&Family _.. _,,$6 65 _ $719.92 <br /> Teamster&Non Bargaining Retirees <br /> Employee Only $346 00 $401.63 <br /> Employee&Spouse $912 00 $1,058.63 <br /> Employee&Child(ren) $685.00 $795.13 <br /> Employee&Family �$�1003.00 $1,164.26 <br />