Empire Total Blue HSA Services In-Network Benefits Network Deductible Individual - $3,000 (A) § Empire BlueCard EPO Family - $6,000 (A) Out-of-Pocket Maximum Individual - $4,275 (A) Family - $8,550 (A) Plan Primary Care / Specialist 30% after Deductible § 1/1/2022 – 12/31/2022 Urgent Care / Walk In Clinic 30% after Deductible Emergency Room 30% after Deductible Provider Search Labs 30% after Deductible Radiology 30% after Deductible www.empireblue.com High-Cost Diagnostics 30% after Deductible In-Patient Hospitalization 30% after Deductible Additional Information Out-Patient Surgery 30% after Deductible § Benefits Summary Durable Medical Equipment 30% after Deductible Prescription Drugs Deductible Included in Medical § Sydney Flyer Tier 1 $15 Tier 2 $35 § Be Active Flyer Tier 3 $75 Mail Order 2x