|  | | |
| Plan | Bronze 60 HDHP 7000/0 (shop) | Bronze 60 HMO 5400/60 (shop) | Bronze 60 HMO 6300/65 (shop) |
| Metal | Bronze | Bronze | Bronze |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $7000/$14,000 family | $5400/$10,800 family | $6300/$12,600 family |
| Coinsurance | 100% coverage for most services | 50% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $7000/$14,000 family | $8200/16,400 family | $8200/16,400 family |
| Ambulance | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Emergency Room | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Hospital | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 100% coverage (after deductible) | 50% coverage (after ded) | Lab $40/X-ray 60% coverage (after ded) |
| Office Visit | 100% coverage (after deductible) | $60 copay first 3 visits then deductible applies | $65 copayment first 3 visits then deductible applies |
| Specialist | 100% coverage (after deductible) | $80 copay first 3 visits then deductible applies | $95 copayment first 3 visits then deductible applies |
| Outpatient Surgery | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Physical Therapy | 100% coverage (after deductible) | $65 copayment | $65 copayment |
| Inpatient Psych | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) |
| Outpatient Psych | 100% coverage (after deductible) | $60 copay first 3 visits then deductible applies | $65 copayment first 3 visits then deductible applies |
| Rx Tier 1 | 100% coverage (after deductible) | $20 copay | $500 Rx ded then $18 ded per Rx |
| Rx Tier 2 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 ($500 Rx ded applies) |
| Rx Tier 3 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 ($500 Rx ded applies) |
| Rx Tier 4 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 ($500 Rx ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Ana | 705.06 | 735.12 | 749.43 |
| Deana | 266.75 | 278.12 | 283.53 |
| Total | 971.81 | 1013.24 | 1032.96 |