OXFORD 5000/10000 HSA BASE PLAN Services In-Network Benefits Network Annual Deductible Individual - $5,000 (E) ▪ EPO Choice Network Family - $10,000 (E) Out-of-Pocket Maximum Individual - $6,650 (E) Family - $13,300 (E) Plan Primary Care & Specialist Visit 100% Coinsurance after Deductible ▪ 5/1/2021 – 4/30/2022 Urgent Care & Walk-In Visits 100% Coinsurance after Deductible Emergency Room Visit 100% Coinsurance after Deductible Provider Search Labs 100% Coinsurance after Deductible Radiology 100% Coinsurance after Deductible www.myuhc.com High-Cost Diagnostics 100% Coinsurance after Deductible In-Patient Hospitalization 100% Coinsurance after Deductible Additional Information Out-Patient Surgery 100% Coinsurance after Deductible ▪ Benefits Summary Durable Medical Equipment 100% Coinsurance after Deductible Prescription Drugs Deductible Subject to Deductible Tier 1 $5 Tier 2 $25 Tier 3 50% to $250 Max Mail Order 2.5x 11 11