| $5,000 PPO | In-Network | Out-of-Network |
| Physician Office Visit |
Primary Care Physician: $0 Copay Specialist: $100 Copay |
Deductible then Coinsurance |
| Calendar Year Deductible | $5,000 Single / $10,000 Family | $10,000 Single / $20,000 Family |
| Coinsurance (Plan Pays / You Pay) | 80% / 20% |
50% / 50% |
| Out-of-Pocket Maximum | $6,500 Single / $13,000 Family | $20,000 / $40,000 Family |
| Annual Routine Physical | No cost sharing for preventive services | Deductible then Coinsurance |
| Emergency Room Visits | $250 Copayment then Coinsurance | $250 Copayment then Coinsurance |
| Hospital Services | Deductible then Coinsurance | Deductible then Coinsurance |








