Deductible (Single/Family) $0 $0 $2,200/ $4,400 $4,400 / $8,800 $5,000 / $10,000 $10,000/ $20,000 Out-of-Pocket Max (Single/Family) $4,000 / $8,000 $8,000 / $16,000 $4,400 / $8,800 $8,800 / $17,600 $5,000 / $10,000 $10,000 / $20,000 Coinsurance N/A N/A 20% 40% 0% 30% Preventive Care No charge $100 copay No charge 40% after deductible No charge No charge Office Visit Primary/Specialist Visit $10 - $65 copay $195 20% after deductible 40% after deductible 0% after deductible 30% after deductible Scans (MRI, CT, etc.) $75 - $950 copay $1,350 - $2,850 copay 20% after deductible 40% after deductible 0% after deductible 30% after deductible Hospital Services $15 to $2,500 copay Up to $7,000 copay 20% after deductible 40% after deductible 0% after deductible 30% after deductible Emergency Room $375 copay 20% after deductible 40% after deductible 0% after deductible 30% after deductible Urgent Care Centers $35 copay $105 copay 20% after deductible 40% after deductible 0% after deductible 30% after deductible Surest Core HDHP IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK Basic HDHP IN NETWORK OUT-OF-NETWORK