Medical Plan Options CONSUMER DRIVEN HEALTH PLAN (CDHP) In-Network Out-of-Network Deductible $1,600 member / $3,200 family $3,000 member / $6,000 family Out-of-Pocket Max $6,150 member / $13,500 family $12,300 member / $27,000 family Routine Physical Covered at 100% Covered at 100% PCP Office Visit 20% coinsurance 40% after deductible Specialist Visit 20% coinsurance 40% after deductible Emergency Room Visit 20% coinsurance 20% after deductible Diagnostic Lab/X-Ray 20% coinsurance 40% after deductible Imaging 20% coinsurance 40% after deductible Inpatient Care 20% coinsurance 40% after deductible Outpatient Care 20% coinsurance 40% after deductible Prescriptions (30-day retail / 90-day mail-order) Generic 20% after deductible / 20% after deductible 40% after deductible / 40% after deductible Preferred brand 20% after deductible / 20% after deductible 40% after deductible / 40% after deductible Non-Preferred Brand 20% after deductible / 20% after deductible 40% after deductible / 40% after deductible Specialty 20% after deductible / 20% after deductible 40% after deductible / 40% after deductible Rx Out-of-Pocket Max Combined with medical Combined with medical *Services from out-of-network providers may be subject to balance billing (member would be responsible 8 for any difference between the allowance and the provider’s actual charge).