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| Plan | Bronze 60 HDHP 7000/0 (shop) | Bronze 60 HMO 5400/60 (shop) | Bronze 60 HMO 6300/65 (shop) | Trio Silver 70 HMO 2250/55 w Child Dental (shop) | Silver 70 HDHP HMO 2500/20 (shop) | Silver 70 HMO 2600/55 (shop) | Silver 70 HMO 2100/55 (shop) | Silver 70 HMO 2250/55 (shop) | Silver 70 HMO 1650/55 (shop) | Trio Gold 80 HMO 250/35 w Child Dental (shop) | Gold 80 HMO 1000/40 (shop) | Trio Platinum 90 HMO 0/20 w Child Dental (shop) | Gold 80 HMO 250/35 (shop) | Gold 80 HMO 0/30 (shop) | Platinum 90 HMO 0/20 (shop) | Platinum 90 HMO 0/10 (shop) | Gold 80 PPO 350/25 w Child Dental (shop) | Platinum 90 PPO 0/15 w Child Dental (shop) |
| Metal | Bronze | Bronze | Bronze | Silver | Silver | Silver | Silver | Silver | Silver | Gold | Gold | Platinum | Gold | Gold | Platinum | Platinum | Gold | Platinum |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Trio ACO Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Trio ACO Network | Kaiser Permanente | Trio ACO Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Full PPO Network | Full PPO Network |
| Deductible | $7000/$14,000 family | $5400/$10,800 family | $6300/$12,600 family | $2250/$4500 family | $2500 (fam cov $2800 ind or $5000 fam) | $2600/$5200 family | $2100/$4200 family | $2250/$4500 family | $1650/$3300 family | $250/$500 family | $1000 ($2000 family) | None | $250 ($500 family) | None | None | None | $350/$700 family | None |
| Coinsurance | 100% coverage for most services | 50% coverage for most services | 60% coverage for most services | 80% coverage for most services | 80% coverage for most services | 55% coverage for most services | 55% coverage for most services | 70% coverage for most services | 60% coverage for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | 80% coverage for most services | 90% coverage for most services |
| Out of Pocket Mzx | $7000/$14,000 family | $8200/16,400 family | $8200/16,400 family | $8200/$16,400 family | $6850/13,700 family | $8200/16,400 family | $8200/16,400 family | $8200/16,400 family | $8200/16,400 family | $7800/$15,600 family | $7800/15,600 family | $4500/9000 family | $7800/15,600 family | $7000/14,000 family | $4500/$9000 family | $3000/$6000 family | $7800/$15,600 family | $4500/9000 family |
| Ambulance | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (after ded) | 80% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | $250 copayment | $350 copayment (after ded) | $150 copayment | $250 copayment (after ded) | $250 copayment (after ded) | $150 copayment | $150 copayment | 80% coverage | $150 copayment |
| Chiropractor | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered |
| Durable Med Equip | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (ded waived) | 80% coverage (ded applies) | 55% coverage | 55% coverage | 70% coverage | 60% coverage (after ded) | 80% coverage | 80% coverage | 90% coverage | 80% coverage (after ded) | 80% coverage (after ded) | 90% coverage | 90% coverage | 80% coverage | 90% coverage |
| Emergency Room | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (after ded) | 80% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | $250 copayment | $350 copayment (after ded) | $150 copayment | $250 copayment (after ded) | $250 copayment (after ded) | $150 copay | $200 copay | $250 copayment | $200 copayment |
| Hospital | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (after ded) | 80% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | $600 per day 1st 5 days | $600 per day 1st 5 days (ded applies) | $250 per day 1st 5 days | $600 per day 1st 5 days | $600 per day 1st 5 days | $250 per day 1st 5 days | $500 per admission | 80% coverage (after deductible) | 90% coverage |
| Infertility | Optional | Optional | Optional | Not covered | Optional | Optional | Optional | Optional | Optional | Not covered | Optional | Not covered | Optional | Optional | Optional | Optional | Not covered | Not covered |
| Lab & X-Ray | 100% coverage (after deductible) | 50% coverage (after ded) | Lab $40/X-ray 60% coverage (after ded) | $55 lab/$90 X-ray | 80% coverage (ded applies) | $30 lab/$75 X-ray | $30 lab/$75 X-ray | $55 lab/$90 X-ray | $30 lab/$75 X-ray after ded | $35 lab/$55 X-ray | $30 lab/$60 X-ray | Lab $20 copay / X-ray $30 copay | $35 lab/$55 X-ray | $30 lab/$40 X-ray | $20 lab/$30 X-ray | $20 lab/$40 X-ray | $25 lab/$65 X-ray | Lab $15 copay / X-ray $30 copay |
| Office Visit | 100% coverage (after deductible) | $60 copay first 3 visits then deductible applies | $65 copayment first 3 visits then deductible applies | $55 copayment | 80% coverage (ded applies) | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $25 copayment | $40 copayment | $20 copayment | $35 copayment | $30 copayment | $20 copayment | $10 copayment | $25 copayment | $15 copayment |
| Specialist | 100% coverage (after deductible) | $80 copay first 3 visits then deductible applies | $95 copayment first 3 visits then deductible applies | $90 copayment | 80% coverage (ded applies) | $80 copayment | $80 copayment | $90 copayment | $80 copayment | $65 copayment | $60 copayment | $30 copayment | $55 copayment | $35 copayment | $30 copayment | $20 copayment | $50 copayment | $30 copayment |
| Outpatient Surgery | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (after ded) | 80% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | $300 copayment | $350 copayment (ded applies) | $100 copayment | $335 copayment | $320 copayment | $125 copayment (per procedure) | $300 copayment (per procedure) | 80% coverage | 90% coverage |
| Physical Therapy | 100% coverage (after deductible) | $65 copayment | $65 copayment | $55 copayment | 80% coverage (ded applies) | $65 copayment | $65 copayment | $55 copayment | $65 copayment | $25 copayment | $30 copayment | $20 copayment | $35 copayment | $30 copayment | $20 copayment | $10 copayment | $25 copayment | $15 copayment |
| Inpatient Psych | 100% coverage (after deductible) | 50% coverage (after ded) | 60% coverage (after ded) | 70% coverage (after ded) | 80% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | $600 per day 1st 5 days | $600 per day 1st 5 days (ded applies) | $250 per day 1st 5 days | $600 per day 1st 5 days | $600 per day 1st 5 days | $250 per day 1st 5 days | $500 per admission | 80% coverage (after deductible) | 90% coverage |
| Outpatient Psych | 100% coverage (after deductible) | $60 copay first 3 visits then deductible applies | $65 copayment first 3 visits then deductible applies | $55 copayment | 80% coverage (ded applies) | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $25 copayment | $40 copayment | $15 copayment | $35 copayment | $30 copayment | $20 copayment | $10 copayment | $25 copayment | $15 copayment |
| Rx Tier 1 | 100% coverage (after deductible) | $20 copay | $500 Rx ded then $18 ded per Rx | $17 copayment (after $300 Rxd ed) | 80% coverage to $250 (med ded applies) | $20 copay | $20 copay | $500 Rx ded then $17 ded per Rx | $20 copay | $15 copayment | $20 copayment | $5 copayment | $15 copayment | $15 copayment | $5 copayment | $5 copayment | $15 copayment | $10 copayment |
| Rx Tier 2 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 (med ded applies) | $80 copayment (after $300 Rx ded) | 80% coverage to $250 (med ded applies) | $75 copay (after med ded) | $75 copay (after $500 Rx ded) | $65 copay (after $300 Rx ded) | $75 copay (after $350 Rx ded) | $40 copayment | $50 copay (after $250 Rx ded) | $20 copayment | $40 copayment | $40 copayment | $20 copayment | $15 copayment | $50 copayment | $25 copayment |
| Rx Tier 3 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 (med ded applies) | $110 copayment (after $300 Rxded) | 80% coverage to $250 (med ded applies) | $75 copay (after med ded) | $75 copay (after $500 Rx ded) | $65 copay (after $300 Rx ded) | $75 copay (after $350 Rx ded) | $70 copayment | $50 copay (after $250 Rx ded) | $30 copayment | $40 copayment | $40 copayment | $20 copayment | $15 copayment | $80 copayment | $40 copayment |
| Rx Tier 4 | 100% coverage (after deductible) | 50% coverage to $500 (med ded applies) | 60% coverage to $500 (med ded applies) | 70% coverage up to $250 per Rx (after $300 Rxded) | 80% coverage to $250 (med ded applies) | 55% coverage to $250 (plan ded applies) | 80% cov $250 max (after $500 Rx ded) | 80% cov $250 max ben (after $300 Rx ded) | 80% cov $250 max ben (after $350 Rx ded) | 80% coverage up to $250 per Rx | 80% coverage to $250 (after $250 Rx ded) | 90% coverage (up to $250 per Rx) | 80% coverage to $250 | 80% coverage to $250 max | 90% cov up to $250 per Rx | 90% cov up to $250 per Rx | 80% coverage up to $250 per Rx | 90% coverage (up to $250 per Rx) |
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| Jose Vilchez / Sp/ 2 | 373.09 fam 1184.2 | 390.73 fam 1239.54 | 398.54 fam 1264.04 | 422.92 fam 1326.52 | 432.04 fam 1369.12 | 454.22 fam 1438.69 | 461.97 fam 1462.99 | 467.17 fam 1479.31 | 470.51 fam 1489.79 | 505.32 fam 1584.97 | 519.65 fam 1643.91 | 548.8 fam 1721.36 | 550.22 fam 1739.79 | 582.85 fam 1842.16 | 612.2 fam 1934.2 | 623.53 fam 1969.74 | 694.51 fam 2178.39 | 774.29 fam 2428.61 |
| M26 Vilchez | 223.94 | 234.53 | 239.22 | 253.85 | 259.33 | 272.64 | 277.29 | 280.41 | 282.42 | 303.31 | 311.91 | 329.41 | 330.26 | 349.85 | 367.46 | 374.26 | 416.87 | 464.75 |
| M28 Vilchez | 237.72 | 248.96 | 253.93 | 269.47 | 275.28 | 289.41 | 294.35 | 297.66 | 299.79 | 321.97 | 331.1 | 349.68 | 350.58 | 371.37 | 390.07 | 397.29 | 442.52 | 493.35 |
| Total | 834.75 w deps 1645.86 | 874.22 w deps 1723.03 | 891.69 w deps 1757.19 | 946.24 w deps 1849.84 | 966.65 w deps 1903.73 | 1016.27 w deps 2000.74 | 1033.61 w deps 2034.63 | 1045.24 w deps 2057.38 | 1052.72 w deps 2072.00 | 1130.60 w deps 2210.25 | 1162.66 w deps 2286.92 | 1227.89 w deps 2400.45 | 1231.06 w deps 2420.63 | 1304.07 w deps 2563.38 | 1369.73 w deps 2691.73 | 1395.08 w deps 2741.29 | 1553.90 w deps 3037.78 | 1732.39 w deps 3386.71 |