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Empire Total Blue HSA Services In-Network Benefits Individual - $3,000 Deductible (A) Family - Network $6,000 (A) Empire BlueCard EPO Individual - $4,275 Out-of-Pocket Maximum (A) Family - $8,550 (A) Primary Care / Specialist 30% after Deductible Plan Urgent Care / Walk In Clinic 30% after Deductible 01/01/2023 – 12/31/2023 Emergency Room 30% after Deductible Labs 30% after Deductible Radiology 30% after Deductible Provider Search High-Cost Diagnostics 30% after Deductible •www.empireblue.com In-Patient Hospitalization 30% after Deductible Out-Patient Surgery 30% after Deductible Durable Medical Equipment 30% after Deductible Additional Information Prescription Drugs Deductible Included in Medical Tier 1 $15 Tier 2 $35 Tier 3 $75 Mail Order 2x

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