Medical Plan Options OPEN ACCESS PLUS PPO In-Network Out-of-Network Deductible $500 member / $1,500 family $1,000 member / $3,000 family Out-of-Pocket Max $2,250 member / $4,500 family $6,000 member / $11,000 family Routine Physical Covered at 100% Covered at 100% PCP Office Visit $5 copay (tiered) / $25 copay (non-tiered) Not covered (tiered) / 40% after deductible (non-tiered) Specialist Visit $20 copay (tiered) / $40 copay (non-tiered) Not covered (tiered) / 40% after deductible (non-tiered) Emergency Room Visit $150 copay $150 copay Diagnostic Lab/X-Ray 20% after deductible 40% after deductible Imaging 20% after deductible 40% after deductible Inpatient Care 20% after deductible 40% after deductible Outpatient Care 20% after deductible 40% after deductible Prescriptions (30-day retail / 90-day mail-order) Generic $10 / $20 Not covered Preferred brand $30 / $40 Not covered Non-Preferred Brand $50 / $150 Not covered Specialty $150 / $300 Not covered Rx Out-of-Pocket Max $3,000 member / $9,000 family N/A *Services from out-of-network providers may be subject to balance billing (member would be responsible for any difference between the allowance and the provider’s actual charge). 7