Deductible* $1,500 / $3,000 (EE only / EE + Spouse/Child/Family) $3,000 / $6,000 (EE only / EE + Spouse/Child/Family) $1,650 / $3,300 (EE only / EE + Spouse/Child/Family) $3,300 / $6,600 (EE only / EE + Spouse/Child/Family) $4,000 / $8,000 (EE only / EE + Spouse/Child/Family) $5,500 / $11,000 (EE only / EE + Spouse/Child/Family) Out-of-Pocket Max $4,000 / $8,000 (EE only / EE + Spouse/Child/Family) $5,000 / $10,000 (EE only / EE + Spouse/Child/Family) $4,000 / $8,000 (EE only / EE + Spouse/Child/Family) $5,000 / $10,000 (EE only / EE + Spouse/Child/Family) $5,000 / $10,000 (EE only / EE + Spouse/Child/Family) $6,500 / $13,000 (EE only / EE + Spouse/Child/Family) Coinsurance 10% 20% 10% 20% 10% 20% Preventive Care Covered Covered Covered Covered Covered Covered Primary Care $30 $60 Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Specialist Visit $50 $100 Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Emergency Room $250, then deductible + coinsurance $250, then deductible + coinsurance $250, then deductible + coinsurance Urgent Care Centers $75 Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance Deductible + coinsurance PPO PLAN Embedded deductible TIER ONE TIER TWO HSA PLAN ONE Non-embedded deductible TIER ONE TIER TWO HSA PLAN TWO Embedded deductible TIER ONE TIER TWO Out-of-Network Benefits Embedded Deductible $6,000 / $12,000 $6,600 / $13,200 $11,000 / $22,000 Out-of-Pocket Max $12,000 / $24,000 $13,200 / $26,400 $22,000 / $44,000 Coinsurance 50% 50% 50% *Embedded deductible applies separately to individuals within a family plan, so once one person meets their individual deductible, their coverage begins—even if the family deductible isn't met. Non-embedded deductible requires the entire family deductible to be met before any individual’s coverage kicks in. For more information on the deductibles and out of pocket maximums please see the medical information in the benefits hub here