MEDICAL PLAN Preferred Blue PPO $2,000 In-Network Out-of-Network BCBS Plan Deductible $2,000 individual / $4,000 family $2,000 individual / $4,000 family Your Deductible Responsibility $500 individual / $1,000 family $500 individual / $1,000 family ABC’s HRA Deductible Contribution $1,500 individual / $3,000 family $1,500 individual / $3,000 family Out-of-Pocket Maximum Medical - $5,450 individual / $10,900 family Medical - $5,450 individual / $10,900 family Rx - $1,000 individual / $2,000 family Rx - $1,000 individual / $2,000 family Preventive Visit $0 $0 PCP Office Visit $15 $15 Specialist Visit $15 $15 Telehealth Visit $15 $15 Emergency Room Visit $150 $150 Behavioral Health Visit $15 $15 Acupuncture (up to 12 visits/calendar year) $15 $15 Diagnostic Tests & High-Tech Imaging $0 after deductible $0 after deductible Inpatient Hospitalization $0 after deductible $0 after deductible Outpatient/Day Surgery $0 after deductible $0 after deductible Prescriptions Tier 1 $15 retail / $30 mail $15 retail / $30 mail Tier 2 $30 retail / $60 mail $30 retail / $60 mail Tier 3 $50 retail / $150 mail $50 retail / $150 mail 4// 2023 Employee BenefitGuide download: medical summary of benefits and coverage (SBC) | medical summary of benefits (SOB) visit: BCBS eKit