Gold Buy-Up PPO Buy-Up PPO Core HDHP Basic HDHP IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK Deductible $1,000 / $2,500 $2,500 / $5,000 $1,650/ $3,300 $3,300 / $6,600 $1,650 / $3,300 $3,300 / $6,600 $5,000 / $10,000 $10,000 / $20,000 (Single/Family) Out-of-Pocket Max $3,000 / $6,000 $6,000 / $12,000 $3,000 / $6,000 $8,000 / $16,000 $3,500 / $6,850 $8,000 / $16,000 $5,000 / $10,000 $10,000 / $20,000 (Single/Family) Coinsurance 20% 50% 20% 50% 10% 40% 0% 0% Preventive Care No charge 50% No charge 50% No charge 40% No charge 30% after deductible after deductible after deductible after deductible Primary Care $25 copay 50% $30 copay 50% 10% 40% 0% 30% after deductible after deductible after deductible after deductible after deductible after deductible Specialist Visit $50 copay 50% $60 copay 50% 10% 40% 0% 30% after deductible after deductible after deductible after deductible after deductible after deductible Hospital Services 20% 50% 20% 50% 10% 40% 0% 30% after deductible after deductible after deductible after deductible after deductible after deductible after deductible after deductible Emergency Room $300 copay $300 copay 10% 10% 0% 0% after deductible after deductible after deductible after deductible Urgent Care Centers $50 copay 50% $50 copay 50% 10% 14% 0% 0% after deductible after deductible after deductible after deductible after deductible after deductible