HSA Qualified Plan PPO Plan IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK Deductible (Single/Family) $2,500 / $5,000 $2,500 / $5,000 $1,300 / $3,900 $2,600 / $7,800 Out-of-Pocket Max (Single/Family) $4,750 / $8,250 $6,450 / $12,900 $4,050 / $9,750 $12,150 / $29,250 Coinsurance 80% 50% 80% 50% Preventive Care No charge No charge No charge No charge Physician Office Visit 20% after deductible 50% after deductible 20% after deductible 50% after deductible Specialist Visit 20% after deductible 50% after deductible 20% after deductible 50% after deductible Emergency Room 20% after deductible 50% after deductible 20% after deductible 50% after deductible Urgent Care Centers 20% after deductible 50% after deductible 20% after deductible 50% after deductible