Medical Blue Cross Blue B730ADT G8K6ADT Shield $7,850 HDHP Plan $2,400 PPO Plan PPO Network Blue Advantage Blue Advantage Individual: $2,400 Individual: $7,850 Family: $7,200 Plan Year Deductible Family: $15,700 Individual: $7,750 Individual: $7,850 Family: $15,500 Out-Of-Pocket Maximum Family: $15,700 No cost after 10% Coinsurance deductible Preventive Care visit/ screening Covered in full Covered in full Primary Care: $35 Specialist: $55 Urgent Care: $50 No cost after Office Visit Copay deductible No cost after $250 Copay, then deductible & coinsurance Emergency Room deductible No cost after Deductible & coinsurance Outpatient Services deductible $200 and Deductible & No cost after coinsurance Inpatient Hospital Services deductible Effective: January 1, 2027 Amounts shown below are your responsibility. This table only shows in-network benefits www.bcbsok.com / 866-520-2507 6