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1 1' " <br />Exhibit A <br />City of South Bend Health insurance Program - 2015 <br />PPO Benefit Plan HRA Benefit Plan r <br />a - . <br />Current - 2014 <br />New - 2015 <br />Current - 2014 <br />New - 2015 <br />HRA Funds Single/Family <br />NA <br />NA <br />$500 1$1,000 <br />$500 1$1,000 <br />Deductible - Single <br />$750 <br />$1,000 <br />$2,500 <br />$2,500 <br />Deductible - Family <br />$2,250 <br />$3,000 <br />$5,000 <br />$5,000 <br />Coinsurance <br />80% <br />80% <br />80 "/0 <br />80% <br />Out -of- Pocket Maximum - Single <br />$3,000 <br />$4,000 <br />$5,000 <br />$5,000 <br />Out -of- Pocket Maximum - Family <br />$6,000 <br />$8,000 <br />$10,000 <br />$10,000 <br />Office Visit Copay - PCP <br />$30 <br />$30 <br />Deductible & Coinsurance Apply <br />Office Visit Co pay - Specialist <br />$40 <br />$60 <br />Deductible & Coinsurance Apply <br />Urgent Care <br />$50 <br />$50 <br />Deductible & Coinsurance Apply <br />Emergency Room <br />$100+20% <br />$200+20% <br />Deductible & Coinsurance Apply <br />Preventive Care <br />100% <br />100% <br />100% <br />Rx - Retail <br />20%,30%,40% <br />20%,30%,40% <br />Deductible & Coinsurance Apply <br />mployeeosthare (B11GIonthly) - IV�Ilness'- grogram Parhapation* 4 <br />_ <br />a - . <br />Current - 2014 <br />New - 2015 <br />Current - 2014 <br />New - 2015 <br />Employee Only <br />$23.98 <br />$27.58 <br />$18.53 <br />$18.53 <br />Employee & Spouse/Dom Partner <br />$71.58 <br />$89.47 <br />$56.67 <br />$56.67 <br />Employee & Child(ren) <br />$48.21 <br />$55.44 <br />$38.15 <br />$38.15 <br />Employee & Family <br />$82.33 <br />$98.79 <br />$63.12 <br />$63.12 <br />Employee & Spouse/Dom Part w /Surchar e <br />NA <br />$114.47 <br />NA <br />$116.67 <br />Employee & Family w /Surcharge <br />NA <br />$123.79 <br />NA <br />$123.12 <br />Employee Cost Share (B- Monthly) -Opt out of W @7luess Program <br />- _ . <br />a - . <br />Current - 2014 <br />New - 2015 <br />Current - 2014 <br />New - 2015 <br />Employee Only <br />$53.98 <br />$64.78 <br />$48.53 <br />$48.53 <br />Employee & Spouse/Dom Partner <br />$131.58 <br />$171.05 <br />$116.67 <br />$116.67 <br />Employee & Child(ren) <br />$78.21 <br />$93.85 <br />$68.15 <br />$68.15 <br />Employee & Family <br />$142.33 <br />$177.91 <br />$123.12 <br />$123.12 <br />Employee & Spouse/Dom Part w /Surchar e <br />NA <br />$196.05 <br />NA <br />$116.67 <br />Employee & Family w /Surchar e <br />NA <br />$202.91 <br />NA <br />$123.12 <br />;Rehree,Cost $harerP -er Month Active Union,Members. <.. <br />a - . <br />Current - 2014 <br />New - 2015 <br />Current - 2014 <br />1 New - 2015 <br />Employee Only <br />$154.22 <br />$185.06 <br />$92.74 <br />$111.43 <br />Employee & Spouse/Dom Partner <br />$474.23 <br />$569.08 <br />$279.94 <br />$336.37 <br />Employee & Child(ren) <br />$342.65 <br />$411.18 <br />$206.24 <br />$247.81 <br />Employee & Family <br />$738.21 <br />$885.85 <br />$433.44 <br />$520.81 <br />x Refuee Cost SharaPel Month Nop Active Umon Members <br />a - . <br />Current - 2014 <br />New - 2015 <br />Current - 2014 <br />New - 2015 <br />Employee Only <br />Abovera[e +$50 <br />Above rate <br />Above rate <br />Above rate +$50 <br />Employee & Spouse/Dom Partner <br />Above rate+ $50 <br />Above rate+ $50 <br />Above rate+ $50 <br />Above rate+ $50 <br />Employee & Child(ren) <br />Above rate+ $50 <br />Above rate + $50 <br />Above rate + $50 <br />Above rate+ $50 <br />Employee & Family <br />Above rate + $50 <br />Above rate + $50 <br />Above rate + $50 <br />Above rate + $50 <br />