PPO PLAN HSA PLAN ONE HSA PLAN TWO Non-embedded deductible TIER ONE TIER TWO TIER ONE TIER TWO TIER ONE TIER TWO Embedded Deductible $1,500 / $3,000 $3,000 / $6,000 $1,650 / $3,300 $3,300 / $6,600 $4,000 / $8,000 $5,500 / $11,000 (Single/Family) Out-of-Pocket Max $4,000 / $8,000 $5,000 / $10,000 $4,000 / $8,000 $5,000 / $10,000 $5,000 / $10,000 $6,500 / $13,000 (Single/Family) Coinsurance 10% 20% 10% 20% 10% 20% Preventive Care Covered Covered Covered Covered Covered Covered Primary Care $30 $60 Deductible + Deductible + Deductible + Deductible + coinsurance coinsurance coinsurance coinsurance Specialist Visit $50 $100 Deductible + Deductible + Deductible + Deductible + coinsurance coinsurance coinsurance coinsurance Emergency Room $250, then deductible + coinsurance $250, then deductible + coinsurance $250, then deductible + coinsurance Urgent Care Centers $75 Deductible + Deductible + Deductible + Deductible + Deductible + coinsurance coinsurance coinsurance coinsurance coinsurance Embedded Deductible $6,000 / $12,000 $6,600 / $13,200 $11,000 / $22,000 Out-of-Network Benefits Out-of-Pocket Max $12,000 / $24,000 $13,200 / $26,400 $22,000 / $44,000 Coinsurance 50% 50% 50%