|  | | |
| Plan | Bronze 60 HMO 6300/65 (shop) | Silver 70 HMO 1800/55 (shop) | Gold 80 HRA |
| Metal | Bronze | Silver | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $6300/$12,600 family | $1800/$3600 family | $2250/$4500 family |
| Coinsurance | 60% coverage for most services | 55% coverage for most services | 75% coverage for most services |
| Out of Pocket Mzx | $7800/15,600 family | $7800/15,600 family | $7800/15,600 family |
| Ambulance | 60% coverage (after ded) | 55% coverage (after deductible) | 75% coverage (after deductible) |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | 55% coverage (after deductible) | 50% coverage (ded applies) |
| Emergency Room | 60% coverage (after ded) | 55% coverage (after deductible) | 75% coverage after ded |
| Hospital | 60% coverage (after ded) | 55% coverage (after deductible) | 75% coverage after ded |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) | rabaLy $25 after ded/X-ray $55 after ded | 75% coverage after ded |
| Office Visit | $65 copayment first 3 visits then deductible applies | $55 copayment | $35 copayment |
| Specialist | $95 copayment first 3 visits then deductible applies | $75 copayment | $50 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 55% coverage (after deductible) | 75% coverage (after deductible) |
| Physical Therapy | $65 copayment | $65 copayment | $35 copayment (ded applies) |
| Inpatient Psych | 60% coverage (after ded) | 55% coverage (after deductible) | 75% coverage after ded |
| Outpatient Psych | $65 copayment first 3 visits then deductible applies | $55 copayment | $35 copayment |
| Rx Tier 1 | $500 Rx ded then $18 ded per Rx | $20 copay | $15 copayment |
| Rx Tier 2 | $500 Rx ded then $500 max ben per Rx | $75 copay (after $350 Rx ded) | $30 copayment (aftr $100 Rx ded) |
| Rx Tier 3 | $500 Rx ded then $500 max ben per Rx | $75 copay (after $350 Rx ded) | $30 copayment (aftr $100 Rx ded) |
| Rx Tier 4 | $500 Rx ded then $500 max ben per Rx | 80% cov $250 max ben (after $350 Rx ded) | 80% cov up to $250 per Rx after $100 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Adrian Valencia | 253.28 | 294.65 | 323.38 |
| Andrew Ortega | 226.02 | 262.94 | 288.58 |
| Brandon Dwyer | 253.28 | 294.65 | 323.38 |
| Brian Cervantes | 238.6 | 277.58 | 304.64 |
| Bruno Diaz | 238.6 | 277.58 | 304.64 |
| Carlos R Morales | 279.15 | 324.74 | 356.41 |
| Cesar Ventura | 264.47 | 307.66 | 337.66 |
| Christian Franco-Bue | 286.6 | 333.42 | 365.93 |
| Daniel Mejia | 669.44 | 778.78 | 854.72 |
| Daniel Torres Jr | 253.28 | 294.65 | 323.38 |
| Eric Jimenez | 288.47 | 335.58 | 368.31 |
| Guardado, Gilberto | 233.01 | 271.07 | 297.5 |
| Hector Pesquera | 632.39 | 735.68 | 807.42 |
| Hugo Marroquin | 380.97 | 443.2 | 486.41 |
| Jaime Espinoza-Ayala | 475.34 | 552.98 | 606.9 |
| Jaime Roas | 434.56 | 505.55 | 554.84 |
| Jessie Manzo | 233.94 | 272.15 | 298.69 |
| Jesus Avelino-Ramos | 284.74 | 331.25 | 363.55 |
| Jesus Lopez-Arteaga | 270.06 | 314.17 | 344.8 |
| Jorge Baez-Lozano | 303.38 | 352.93 | 387.35 |
| Jose Castro | 233.01 | 271.07 | 297.5 |
| Juan Lopez Jr | 233.01 | 271.07 | 297.5 |
| Juan Pablo-Camacho | 303.38 | 352.93 | 387.35 |
| Kurt Withans | 567.85 | 660.6 | 725.01 |
| Leonardo Ibarra | 336.47 | 391.43 | 429.59 |
| Lorenzo Navarrete | 288.47 | 335.58 | 368.31 |
| Marco Ventura-Lopez | 349.52 | 406.61 | 446.25 |
| Mark Lopez | 260.74 | 303.33 | 332.9 |
| Mauricio Aguilar-Cor | 286.6 | 333.42 | 365.93 |
| Michael Banuelos | 264.47 | 307.66 | 337.66 |
| Michael Podratz | 416.16 fam 832.32 | 484.13 fam 968.26 | 531.34 fam 1062.68 |
| Michaela Zavala | 284.74 | 331.25 | 363.55 |
| Oscar Torres | 244.19 | 284.08 | 311.78 |
| Robert Pickering | 364.19 | 423.68 | 464.99 |
| Salvador Aguilar | 316.19 | 367.84 | 403.71 |
| Salvador Cano | 288.47 | 335.58 | 368.31 |
| Sergio Fernandez | 308.74 | 359.17 | 394.19 |
| Simon Lozano-Anguian | 260.74 | 303.33 | 332.9 |
| Tyler Valencia | 226.02 | 262.94 | 288.58 |
| Victor Lopez | 416.16 | 484.13 | 531.34 |
| Victor Tarango | 519.61 | 604.49 | 663.43 |
| Total | 13268.31 w deps 13684.47 | 15435.53 w deps 15919.66 | 16940.61 w deps 17471.95 |