SAMPLE MX –MEDICAL PLAN Services In-Network Benefits Network Annual Deductible Individual - $500 (E) ▪ Empire BlueCard EPO Family - $1,250 (E) 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 High-Cost Diagnostics 20% after Deductible Additional Information In-Patient Hospitalization 20% after Deductible Out-Patient Surgery 20% after Deductible ▪ Sydney Flyer Durable Medical Equipment 20% after Deductible Prescription Drugs ▪ Be Active Flyer Deductible No Deductible Tier 1 $10 ▪ COVID Test Locator Tier 2 $35 Tier 3 $70 Mail Order 2x Retail 5