Base Plan Buy-Up Plan Surest Plan IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Embedded Deductible $0.00 / $0.00 $0.00/ $0.00 $0.00/ $0.00 $0.00/ $0.00 $0 $0 (Single/Family) Out-of-Pocket Max $0.00 / $0.00 $0.00/ $0.00 $0.00/ $0.00 $0.00/ $0.00 $0.00/ $0.00 $0.00/ $0.00 (Single/Family) Coinsurance 20% 20% No coinsurance No coinsurance Preventive Care Covered 100% Covered 100% $0 $0 Physician Office Visit Deductible, then coinsurance Deductible, then coinsurance $0 $0 Emergency Room Deductible, then coinsurance Deductible, then coinsurance $0 $0 Urgent Care Centers Deductible, then coinsurance Deductible, then coinsurance $0 $0 Deductible year runs on the calendar year. Coinsurance kicks in once the calendar year deductible is met. Preventive care services include but are not limited to routine wellness exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic eye exam, routine vision and hearing exams. Covers preventive care services rendered in a physician's office and outpatient service centers.