HealthSync HDHP 1 HealthSync HDHP 2 Tier 1 HealthSync Tier 2 In-Network Out-of-Network Tier 1 HealthSync Tier 2 In-Network Out-of-Network Embedded $3,000 / Deductible ($3,300 Individual) $6,000 $5,000 / $10,000 $15,000 / $30,000 $4,000 / $8,000 $5,500 / $11,000 $16,500 / $33,000 (Single/Family) (Family) Embedded Out-of-Pocket Max $7,000 / $14,000 $7,000 / $14,000 $21,000 / $42,000 $7,000 / $14,000 $7,000 / $14,000 $21,000 / $42,000 (Single/Family) Coinsurance 0% 20% 50% 20% 40% 50% Preventive Care 100% Coverage 100% Coverage Deductible, then 100% Coverage 100% Coverage 50% after Deductible coinsurance Primary Care Deductible, then $15 Deductible, then $40 Deductible, then Deductible, then Deductible, then Deductible, then Copay Copay + Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Specialist Visit Deductible, then $30 Deductible, then $80 Deductible, then Deductible, then Deductible, then Deductible, then Copay Copay + Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Hospital 0% after Deductible Deductible, then $500 Deductible, then Deductible, then Deductible, then $500 Deductible, then Inpatient Copay + Coinsurance Coinsurance Coinsurance Copay + Coinsurance Coinsurance Hospital 0% after Deductible Deductible, then $250 Deductible, then Deductible, then Deductible, then $250 Deductible, then Outpatient Copay + Coinsurance Coinsurance Coinsurance Copay + Coinsurance Coinsurance Deductible, then $250 Deductible, then $250 Deductible, then $250 Deductible, then $250 Deductible, then $250 Deductible, then $250 Emergency Room Copay and 0% Copay and 0% Copay and 0% Copay + Coinsurance Copay + Coinsurance Copay + Coinsurance Coinsurance Coinsurance Coinsurance Urgent Care Deductible, then $75 Deductible, then $150 Deductible, then Deductible, then Deductible, then Deductible, then Centers Copay Copay + Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Virtual Visits – 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible 20% after Deductible (Preferred Online Provider)