B IN-NETWORK DEDUCTIBLE COINSURANCE OUT OF POCKET MAXIMUM ER VISIT URGENT CARE FAMILY DOCTOR / SPECIALIST HOSPITAL / MRI / SURGERY / etc. PREVENTIVE VISIT COMPANY HSA CONTRIBUTIONS PHARMACY OUT OF NETWORK HDHP - HSA $4,000 - Individual $8,000 - Family N/A $4,000 - Individual $8,000 - Family UP TO DEDUCTIBLE UP TO DEDUCTIBLE UP TO DEDUCTIBLE UP TO DEDUCTIBLE NO CHARGE +$1,000! UP TO DEDUCTIBLE $8,000 - Individual $16,000 - Family COPAY PLAN $2,500 - Individual $5,000 - Family Member Pays 20% $6,350 - Individual $12,700 - Family $500 $75 $50 / $75 Deductible + Coinsurance, UP TO out-of-pocket max NO CHARGE N/A $10/$50/$90/25% $5,000 - Individual $10,000 - Family A