EMPIRE EPO BP003 PLAN Services Tier 1 – SJMC Providers Tier 2 - Empire Network Network Annual Deductible Individual - $0 (E) Individual - $50 (E) ▪ Empire BlueCard EPO Family - $0 (E) Family - $100 (E) Out-of-Pocket Maximum Individual - $0 (E) Individual - $6,350 (E) Plan Family - $0 (E) Family - $12,700 (E) Primary Care & Specialist Visit No Charge $30 Copay ▪ 1/1/2021 –12/31/2021 Urgent Care & Walk-In Visits No Charge $30 Copay Emergency Room Visit No Charge $50 Copay Provider Search Labs No Charge No Charge www.empireblue.com Radiology No Charge No Charge High-Cost Diagnostics No Charge No Charge Additional Information In-Patient Hospitalization No Charge $100 Copay up to $250 Per Year ▪ Benefits Summary Out-Patient Surgery No Charge No Charge Durable Medical Equipment No Charge No Charge ▪ Sydney Flyer Prescription Drugs Tier 1 $10 $10 ▪ COVID Test Locator Tier 2 $20 $20 Tier 3 $30 $30 Mail Order 2x Retail 2x Retail 13 13