$2,500 COPAY PLAN $4,000 HDHP W/ HSA Employer HSA N/A Match up to $500 Contributions Deductible $2,500 / $5,000 $4,000 / $8,000 (Single/Family) Out-of-Pocket Max $6,250 / $12,500 $7,000 / $14,000 (Single/Family) Coinsurance 20% 20% Preventive Care 100% Coverage 100% Coverage Physician/Specialist DEDUCTIBLE, Visits $40 / $55 Then 20%, Up to Out of Pocket Maximum DEDUCTIBLE, Hospital/Out-Patient 20% after deductible Then 20%, Up to Out of Pocket Maximum DEDUCTIBLE, Emergency Room $500 Then 20%, Up to Out of Pocket Maximum DEDUCTIBLE, Urgent Care Centers $100 Then 20%, Up to Out of Pocket Maximum