In-Network Benefi ts Ou t-of-Network Benefi ts In-Network Benefi ts Ou t-of-Network Benefi ts In-Network Benefi ts Ou t-of-Network Benefi ts Annual Deductible Individual $1,500 $6,000 $1,500 $6,000 $2,500 $6,000 Family $3,000 $12,000 $3,000 $12,000 $5,000 $12,000 Coinsurance 80% after deductible 70% after deductible 70% after deductible 60% after deductible 70% after deductible 60% after deductible Maximum Out-of-Pocket (Includes Deductibles) Individual $4,000 $9,000 $5,000 $10,000 $6,000 $10,000 Family $8,000 $18,000 $10,000 $20,000 $12,000 $20,000 Physician Office Visit Primary Care $30 copay 70% after deductible $30 copay 60% after deductible $30 copay 60% after deductible Specialty Care $60 copay 70% after deductible $60 copay 60% after deductible $60 copay 60% after deductible Preventive Care Adult Periodic Exams 100% 70% after deductible 100% 60% after deductible 100% 60% after deductible Well-Child Care 100% 70% after deductible 100% 60% after deductible 100% 60% after deductible Diagnostic Services X-ray and Lab Tests 100% 70% after deducitble 100% 60% after deducitble 100% 60% after deductible Complex Radiology 80% after deductible 70% after deductible 70% after deductible 60% after deductible 70% after deductible 60% after deductible Urgent Care Facility $50 copay 70% after deductible $50 copay 60% after deductible $50 copay 60% after deductible Emergency Room Facility Charges $250 copay; waived if admitted $250 copay $250 copay; waived if admitted $250 copay $250 copay; waived if admitted $250 copay Inpatient Facility Charges 80% after deductible 70% after deductible 70% after deductible 60% after deductible 70% after deductible 60% after deductible Outpatient Facility and Surgical Charges 80% after deductible 70% after deducitble 70% after deductible 60% after deducitble 70% after deductible 60% after deductible. In-Network Benefi ts Ou t-of-Network Benefi ts In-Network Benefi ts Ou t-of-Network Benefi ts In-Network Benefi ts Ou t-of-Network Benefi ts Mental Health Inpatient 80% after deductible 70% after deductible 70% after deductible 60% after deductible 70% after deductible 60% after deductible Outpatient $30 copay 70% after deductible $30 copay 60% after deductible $30 copay 60% after deductible Substance Abuse Inpatient 80% after deductible 70% after deductible 70% after deductible 60% after deductible 70% after deductible 60% after deductible Outpatient $30 copay 70% after deductible $30 copay 60% after deductible $30 copay 60% after deductible Other Services Chiropractic 50% 50% 50% 50% 50% 50% Retail Pharmacy (30 Day Supply) Tier 1 (Lowest Cost Option) $15 copay $15 copay $15 copay $15 copay $15 copay $15 copay Tier 2 (Mid-Range Option) $40 copay $40 copay $40 copay $40 copay $40 copay $40 copay Tier 3 (Mid Range Option) $75 copay $75 copay $75 copay $75 copay $75 copay $75 copay Tier 4 (Highest Cost Option) 20% up to a $150 maximum 20% up to a $150 maximum 20% up to a $150 maximum 20% up to a $150 maximum 20% up to a $150 maximum 20% up to a $150 maximum Mail Order Pharmacy (90 Day Supply) Tier 1 (Lowest Cost Option) $37.50 copay Not covered $37.50 copay Not covered $37.50 copay Not covered Tier 2 (Mid-Range Option) $100 copay Not covered $100 copay Not covered $100 copay Not covered Tier 3 (Mid Range Option) $187.50 copay Not covered $187.50 copay Not covered $187.50 copay Not covered Tier 4 (Highest Cost Option) 20% up to a $375 maximum Not covered 20% up to a $375 maximum Not covered 20% up to a $375 maximum Not covered IF YOU AND/OR YOUR SPOUSE WILL HAVE COVERAGE UNDER ONE OF THE MEDICAL PLAN OPTIONS BEING OFFERED THIS YEAR, BUT DID NOT PARTICIPATE IN THE WELLNESS PROGRAM, YOU WILL NEED TO ADD THE $50 SURCHARGE ($50 EMPLOYEE AND/OR $50 FOR SPOUSE) TO BELOW PREMIUM RATES.