OXFORD 3000/6000 HSA BUY-UP PLAN Services In-Network Benefits Network Annual Deductible Individual - $3,000 (E) ▪ EPO Choice Network Family - $6,000 (E) Out-of-Pocket Maximum Individual - $6,750 (E) Family - $13,500 (E) Plan Primary Care & Specialist Visit 20% Coinsurance after Deductible ▪ 5/1/2021 – 4/30/2022 Urgent Care & Walk-In Visits 20% Coinsurance after Deductible Emergency Room Visit 20% Coinsurance after Deductible Provider Search Labs 20% Coinsurance after Deductible Radiology 20% Coinsurance after Deductible www.myuhc.com High-Cost Diagnostics 20% Coinsurance after Deductible In-Patient Hospitalization 20% Coinsurance after Deductible Additional Information Out-Patient Surgery 20% Coinsurance after Deductible ▪ Benefits Summary Durable Medical Equipment 20% 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 12 12