EMPIRE PPO BP001 PLAN Services Tier 1 – SJMC Providers Tier 2 - Empire Network Tier 3 – Out-of-Network Network Annual Deductible Individual - $0 (E) Individual - $50 (E) Individual - $400 (E) ▪ Empire BlueCard PPO Family - $0 (E) Family - $100 (E) Family - $950 (E) Out-of-Pocket Maximum Individual - $0 (E) Individual - $6,350 (E) Individual - $2,400 (E) Plan Family - $0 (E) Family - $12,700 (E) Family - $5,950 (E) Primary Care & Specialist Visit No Charge $20 Copay 20% Coinsurance ▪ 1/1/2021 –12/31/2021 Urgent Care & Walk-In Visits No Charge $20 Copay 20% Coinsurance Emergency Room Visit No Charge $50 Copay 20% Coinsurance Provider Search Labs No Charge No Charge 20% Coinsurance www.empireblue.com Radiology No Charge No Charge 20% Coinsurance High-Cost Diagnostics No Charge No Charge 20% Coinsurance Additional Information In-Patient Hospitalization No Charge No Charge 20% Coinsurance ▪ Benefits Summary Out-Patient Surgery No Charge No Charge 20% Coinsurance Durable Medical Equipment No Charge No Charge 20% Coinsurance ▪ Sydney Flyer Prescription Drugs Tier 1 $5 $5 Not Covered ▪ COVID Test Locator Tier 2 $15 $15 Not Covered Tier 3 $25 $25 Not Covered Mail Order 2x Retail 2x Retail Not Covered 12 12