|  |  | |
| Plan | Silver Full PPO Savings 2500/35% OffEx | Silver PPO 55/2500/45% 4J00 | Silver PPO 50/2000/40% 4HWY |
| Metal | Silver | Silver | Silver |
| Network | Full PPO Network | Prudent Buyer PPO | Prudent Buyer PPO |
| Deductible | $2500 or $2800/$5000 family | $2500/$5000 family | $2000/$4000 family |
| Coinsurance | 65% coverage for most services | 55% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $6850/$13,700 family | $8150/$16,300 family | $7900/$15,800 family |
| Ambulance | 65% coverage after ded | 55% coverage (ded applies) | 60% coverage (ded applies) |
| Chiropractor | 65% coverage after ded | Limited coverage | Limited coverage |
| Durable Med Equip | 50% coverage (after deductible) | 50% coverage (ded applies) | 50% coverage (ded applies) |
| Emergency Room | $150 copay then 65% cov after ded | $350 copay then 55% coverage (ded apples) | $350 copayment then 60% coverage (ded applies) |
| Hospital | 65% coverage after ded | 55% coverage (ded applies) | 60% coverage (ded applies) |
| Infertility | Not covered | Not covered | Not covered |
| Lab & X-Ray | 65% coverage after ded | $55 lab/$85 X-ray copayment | $50 lab/$85 X-ray copayment |
| Office Visit | 65% coverage after ded | $55 copayment | $50 copayment |
| Specialist | 65% coverage after ded | $85 copayment | $85 copayment |
| Outpatient Surgery | $150 copayment (then 65% coverage) after ded | 55% coverage (ded applies) | 60% coverage (ded applies) |
| Physical Therapy | 65% coverage after ded | 55% coverage (ded applies) | $50 copayment |
| Inpatient Psych | 65% coverage after ded | 55% coverage (ded applies) | 60% coverage (ded applies) |
| Outpatient Psych | 65% coverage after ded | $55 copayment | $50 copayment |
| Rx Tier 1 | 65% cov up to $250 per Rx after ded | $20 copayment | $20 copayment |
| Rx Tier 2 | 65% cov up to $250 per Rx after ded | $60 copayment | $50 copayment |
| Rx Tier 3 | 65% cov up to $250 per Rx after ded | $100 copayment | $95 copayment after $150 Rx ded |
| Rx Tier 4 | 65% cov up to $250 per Rx after ded | 70% coverage to $250 max $150 Rx ded | 70% coverage to $250 max $150 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Alves | 598.13 fam 1690.31 | 613.41 fam 1733.5 | 627.32 fam 1772.8 |
| Gonzalez | 503.22 fam 2347.44 | 516.08 fam 2407.43 | 527.78 fam 2462 |
| Henry | 813.45 fam 1944.7 | 834.24 fam 1994.4 | 853.15 fam 2039.62 |
| Kraft | 712.17 fam 1863.36 | 730.37 fam 1910.98 | 746.92 fam 1954.29 |
| Lechich | 446.2 | 457.6 | 467.98 |
| Nunez | 400.35 | 410.58 | 419.88 |
| Ortega | 509.6 fam 1006.44 | 522.63 fam 1032.17 | 534.47 fam 1055.56 |
| Patrick | 813.45 | 834.24 | 853.15 |
| Protzen | 889.21 fam 2453.11 | 911.94 fam 2515.8 | 932.61 fam 2572.83 |
| Rivera | 651.96 fam 1275.21 | 668.62 fam 1307.79 | 683.77 fam 1337.43 |
| Rizzo | 1196.25 | 1226.82 | 1254.63 |
| Rodriguez | 398.75 | 408.94 | 418.21 |
| Sorani | 889.21 | 911.94 | 932.61 |
| Tocchini | 651.96 fam 1919.19 | 668.62 fam 1968.23 | 683.77 fam 2012.85 |
| Toriggino | 1082.21 fam 2518.91 | 1109.86 fam 2583.27 | 1135.02 fam 2641.83 |
| Weed | 778.36 fam 1541.17 | 798.25 fam 1580.55 | 816.35 fam 1616.39 |
| Total | 11334.48 w deps 22704.05 | 11624.14 w deps 23284.24 | 11887.62 w deps 23812.06 |