Empire Deductible First Services In-Network Benefits Individual - $1,500 Deductible (E) Family - Network $3,750 (E) Empire BlueCard EPO Individual - $5,000 Out-of-Pocket Maximum (E) Family - $12,000 (E) Primary Care / Specialist $30 / $50 after Deductible Plan Urgent Care / Walk In Clinic $25 after Deductible 01/01/2023 – 12/31/2023 Emergency Room $150 after Deductible Labs $35 / $50 after Deductible Radiology $35 / $50 after Deductible Provider Search High-Cost Diagnostics $0 after Deductible www.empireblue.com In-Patient Hospitalization $500 after Deductible Out-Patient Surgery $200 after Deductible Durable Medical Equipment $0 after Deductible Additional Information Prescription Drugs Deductible Included in Medical Tier 1 $10 Tier 2 $35 Tier 3 $70 Mail Order 2x