Sample MX - Medical Plan Services In-Network Benefits Annual Deductible Individual - $500 (E) Network Family - $1,250 (E) • Empire BlueCard EPO Out-of-Pocket Maximum Individual - $5,000 (E) Family - $12,500 (E) Plan Primary Care & Specialist Visit $35 / $50 • 1/1/2021 – 12/31/2021 Urgent Care & Walk-In Visits $50 Emergency Room Visit $100 Provider Search Labs Office: $35 or $50 Copay / Lab or Hospital: 20% after Deductible www.empireblue.com Radiology Office: $35 or $50 Copay / Lab or Hospital: 20% after Deductible Additional Information High-Cost Diagnostics 20% after Deductible In-Patient Hospitalization 20% after Deductible • Sydney Flyer Out-Patient Surgery 20% after Deductible Durable Medical Equipment 20% after Deductible • Be Active Flyer Prescription Drugs • COVID Test Locator Deductible No Deductible Tier 1 $10 Tier 2 $35 Tier 3 $70 Mail Order 2x Retail