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| Plan | WholeCare HMO Silver $50 | Full Network HMO Silver $50 | SmartCare HMO Gold $50 | SmartCare HMO Gold $40 | SmartCare HMO Gold $30 | SmartCare HMO Platinum $30 | WholeCare HMO Gold $50 | Full Network HMO Gold $50 | WholeCare HMO Gold $40 | SmartCare HMO Platinum $20 | WholeCare HMO Gold $35 | SmartCare HMO Platinum $0 | WholeCare HMO Gold $30 | Full Network HMO Gold $40 | WholeCare HMO Platinum $30 | SmartCare HMO Platinum $10 | WholeCare HMO Platinum $20 | Full Network HMO Gold $35 | WholeCare HMO Platinum $0 | WholeCare HMO Platinum $10 | Full Network HMO Gold $30 | Full Network HMO Platinum $30 | Full Network HMO Platinum $20 | Full Network HMO Platinum $0 | Full Network HMO Platinum $10 |
| Metal | Silver | Silver | Gold | Gold | Gold | Platinum | Gold | Gold | Gold | Platinum | Gold | Platinum | Gold | Gold | Platinum | Platinum | Platinum | Gold | Platinum | Platinum | Gold | Platinum | Platinum | Platinum | Platinum |
| Network | WholeCare HMO | Full Network HMO | SmartCare HMO | SmartCare HMO | SmartCare HMO | SmartCare HMO | WholeCare HMO | Full Network HMO | WholeCare HMO | SmartCare HMO | WholeCare HMO | SmartCare HMO | WholeCare HMO | Full Network HMO | WholeCare HMO | SmartCare HMO | WholeCare HMO | Full Network HMO | WholeCare HMO | WholeCare HMO | Full Network HMO | Full Network HMO | Full Network HMO | Full Network HMO | Full Network HMO |
| Deductible | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None | None |
| Coinsurance | 50% coverage for most services | 50% 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 | 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 | 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 | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7950/$15,900 family | $7950/$15,900 family | $7000,$14,000 family | $6500/$13,000 family | $6000/$12,000 family | $3000/$6000 family | $7000,$14,000 family | $7000,$14,000 family | $6500/$13,000 family | $3000/$6000 family | $6500/$13,000 family | $3000/$6000 family | $6000/$12,000 family | $6500/$13,000 family | $3000/$6000 family | $1750/$3500 family | $3000/$6000 family | $6500/$13,000 family | $3000/$6000 family | $1750/$3500 family | $6000/$12,000 family | $3000/$6000 family | $3000/$6000 family | $3000/$6000 family | $1750/$3500 family |
| Ambulance | 50% coverage | 50% coverage | $300 copayment | $300 copayment | $300 copayment | $200 copayment | $300 copayment | $300 copayment | $300 copayment | $120 copaymet | $300 copayment | $250 copayment (ded applies) | $300 copayment | $300 copayment | $200 copayment | $150 copayment | $120 copaymet | $300 copayment | $250 copayment (ded applies) | $150 copayment | $300 copayment | $200 copayment | $120 copaymet | $250 copayment (ded applies) | $150 copayment |
| Chiropractor | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional |
| Durable Med Equip | 50% coverage | 50% coverage | 60% coverage | 60% coverage | 70% coverage | 80% coverage | 60% coverage | 60% coverage | 60% coverage | 80% coverage | 70% coverage | 70% coverage | 70% coverage | 60% coverage | 80% coverage | 90% coverage | 80% coverage | 70% coverage | 70% coverage | 90% coverage | 70% coverage | 80% coverage | 80% coverage | 70% coverage | 90% coverage |
| Emergency Room | 50% coverage | 50% coverage | $300 copayment | $300 copayment | $300 copayment | $200 copaymet | $300 copayment | $300 copayment | $300 copayment | $200 copaymet | $300 copayment | $250 copayment (ded applies) | $300 copayment | $300 copayment | $200 copaymet | $150 copayment | $200 copaymet | $300 copayment | $250 copayment (ded applies) | $150 copayment | $300 copayment | $200 copaymet | $200 copaymet | $250 copayment (ded applies) | $150 copayment |
| Hospital | 50% coverage | 50% coverage | $850 per day (1st 5 days) | $750 per day (1st 4 days) | $750 per day (1st 3 days) | $350 per day (1st 3 days) | $850 per day (1st 5 days) | $850 per day (1st 5 days) | $750 per day (1st 4 days) | $350 per day (1st 3 days) | $750 per day (1st 3 days) | $500 per day (1st 4 days) | $750 per day (1st 3 days) | $750 per day (1st 4 days) | $350 per day (1st 3 days) | $250 per day (1st 3 days) | $350 per day (1st 3 days) | $750 per day (1st 3 days) | $500 per day (1st 4 days) | $250 per day (1st 3 days) | $750 per day (1st 3 days) | $350 per day (1st 3 days) | $350 per day (1st 3 days) | $500 per day (1st 4 days) | $250 per day (1st 3 days) |
| Infertility | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | $40 copay | $20 copay | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | $20 copay | Lab: $40 copay/X-ray $50 copay | No charge | $40 copay | Lab: $40 copay/X-ray $50 copay | $20 copay | $20 copay | $20 copay | Lab: $40 copay/X-ray $50 copay | No charge | $20 copay | $40 copay | $20 copay | $20 copay | No charge | $20 copay |
| Office Visit | $50 copayment | $50 copayment | $50 copayment | $40 copayment | $30 copayment | $20 copayment | $50 copayment | $50 copayment | $40 copayment | $20 copayment | $35 copayment | No charge | $30 copayment | $40 copayment | $20 copayment | $10 copayment | $20 copayment | $35 copayment | No charge | $10 copayment | $30 copayment | $20 copayment | $20 copayment | No charge | $10 copayment |
| Specialist | $70 copayment | $70 copayment | $70 copayment | $60 copayment | $50 copayment | $40 copayment | $70 copayment | $70 copayment | $60 copayment | $40 copayment | $55 copayment | No charge | $50 copayment | $60 copayment | $40 copayment | $30 copayment | $40 copayment | $55 copayment | No charge | $30 copayment | $50 copayment | $40 copayment | $40 copayment | No charge | $30 copayment |
| Outpatient Surgery | 50% coverage | 50% coverage | $1300 copayment | $1200 copayment | $900 copayment | $500 copayment | $1300 copayment | $1300 copayment | $1200 copayment | $500 copayment | $1200 copayment | $500 copayment | $900 copayment | $1200 copayment | $500 copayment | $150 copayment | $500 copayment | $1200 copayment | $500 copayment | $150 copayment | $900 copayment | $500 copayment | $500 copayment | $500 copayment | $150 copayment |
| Physical Therapy | $50 copayment | $50 copayment | $50 copayment | $40 copayment | $30 copayment | $20 copayment | $50 copayment | $50 copayment | $40 copayment | $20 copayment | $35 copayment | No charge | $30 copayment | $40 copayment | $20 copayment | $10 copayment | $20 copayment | $35 copayment | No charge | $10 copayment | $30 copayment | $20 copayment | $20 copayment | No charge | $10 copayment |
| Inpatient Psych | 50% coverage | 50% coverage | $850 per day (1st 5 days) | $750 per day (1st 4 days) | $750 per day (1st 3 days) | $350 per day (1st 3 days) | $850 per day (1st 5 days) | $850 per day (1st 5 days) | $750 per day (1st 4 days) | $350 per day (1st 3 days) | $750 per day (1st 3 days) | $500 per day (1st 4 days) | $750 per day (1st 3 days) | $750 per day (1st 4 days) | $350 per day (1st 3 days) | $250 per day (1st 3 days) | $350 per day (1st 3 days) | $750 per day (1st 3 days) | $500 per day (1st 4 days) | $250 per day (1st 3 days) | $750 per day (1st 3 days) | $350 per day (1st 3 days) | $350 per day (1st 3 days) | $500 per day (1st 4 days) | $250 per day (1st 3 days) |
| Outpatient Psych | $50 copayment | $50 copayment | $50 copayment | $40 copayment | $30 copayment | $20 copayment | $50 copayment | $50 copayment | $40 copayment | $20 copayment | $35 copayment | No charge | $30 copayment | $40 copayment | $20 copayment | $10 copayment | $20 copayment | $35 copayment | No charge | $10 copayment | $30 copayment | $20 copayment | $20 copayment | No charge | $10 copayment |
| Rx Tier 1 | $20 copayment | $20 copayment | $15 copayment | $15 copayment | $15 copayment | $5 copayment | $15 copayment | $15 copayment | $15 copayment | $5 copayment | $15 copayment | No charge | $15 copayment | $15 copayment | $5 copayment | $5 copayment | $5 copayment | $15 copayment | No charge | $5 copayment | $15 copayment | $5 copayment | $5 copayment | No charge | $5 copayment |
| Rx Tier 2 | 50% (up to $450 per 30 day script after Rx ded) | 50% (up to $450 per 30 day script after Rx ded) | $50 copay (after $450 Rx ded) | $50 copayment | $50 copayment | $30 copayment | $50 copay (after $450 Rx ded) | $50 copay (after $450 Rx ded) | $50 copayment | $30 copayment | $50 copayment | $30 copayment | $50 copayment | $50 copayment | $30 copayment | $30 copayment | $30 copayment | $50 copayment | $30 copayment | $30 copayment | $50 copayment | $30 copayment | $30 copayment | $30 copayment | $30 copayment |
| Rx Tier 3 | 50% (up to $250 per 30 day script after Rx ded) | 50% (up to $250 per 30 day script after Rx ded) | $70 copay (after $450 Rx ded) | $70 copayment | $70 copayment | $50 copayment | $70 copay (after $450 Rx ded) | $70 copay (after $450 Rx ded) | $70 copayment | $50 copayment | $70 copayment | $50 copayment | $70 copayment | $70 copayment | $50 copayment | $50 copayment | $50 copayment | $70 copayment | $50 copayment | $50 copayment | $70 copayment | $50 copayment | $50 copayment | $50 copayment | $50 copayment |
| Rx Tier 4 | 50% cov up to $250 per 30 day script after Rx deductible | 50% cov up to $250 per 30 day script after Rx deductible | 60% cov up to $250 per Rx after $450 Rx deductible | 70% coverage | 70% coverage | 70% cov ($250 max per 30 day script) | 60% cov up to $250 per Rx after $450 Rx deductible | 60% cov up to $250 per Rx after $450 Rx deductible | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% cov ($250 max per 30 day script) | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% coverage | 70% cov ($250 max per 30 day script) | 70% coverage | 70% coverage | 70% coverage |
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| Adriana Loza | 574.46 | 582.88 | 592.29 | 603.99 | 627.65 | 632.43 | 634.05 | 641.95 | 643.98 | 647.89 | 653.78 | 662.19 | 669.22 | 673.06 | 677.01 | 678.91 | 690.78 | 697.53 | 706.04 | 723.85 | 728.55 | 737.04 | 752.05 | 768.66 | 788.05 |
| Antonio Lemus | 773.04 | 784.36 | 797.03 | 812.77 | 844.6 | 851.04 | 853.22 | 863.85 | 866.58 | 871.84 | 879.77 | 891.09 | 900.54 | 905.71 | 911.03 | 913.59 | 929.56 | 938.64 | 950.1 | 974.06 | 980.38 | 991.82 | 1012.01 | 1034.37 | 1060.45 |
| Jon Matsunaga | 756.09 | 767.16 | 779.55 | 794.95 | 826.08 | 832.38 | 834.51 | 844.91 | 847.58 | 852.72 | 860.48 | 871.55 | 880.79 | 885.85 | 891.05 | 893.55 | 909.18 | 918.06 | 929.27 | 952.7 | 958.88 | 970.07 | 989.82 | 1011.68 | 1037.2 |
| Tony Tran | 525.22 fam 1327.31 | 532.92 fam 1346.76 | 541.52 fam 1368.51 | 552.22 fam 1395.55 | 573.85 fam 1450.21 | 578.22 fam 1461.25 | 579.7 fam 1465 | 586.93 fam 1483.26 | 588.78 fam 1487.94 | 592.35 fam 1496.97 | 597.74 fam 1510.58 | 605.43 fam 1530.02 | 611.85 fam 1546.25 | 615.37 fam 1555.13 | 618.98 fam 1564.25 | 620.72 fam 1568.65 | 631.57 fam 1596.07 | 637.74 fam 1611.66 | 645.53 fam 1631.35 | 661.81 fam 1672.49 | 666.1 fam 1683.34 | 673.87 fam 1702.97 | 687.59 fam 1737.65 | 702.78 fam 1776.03 | 720.5 fam 1820.81 |
| Total | 2628.81 w deps 3430.90 | 2667.32 w deps 3481.16 | 2710.39 w deps 3537.38 | 2763.93 w deps 3607.26 | 2872.18 w deps 3748.54 | 2894.07 w deps 3777.10 | 2901.48 w deps 3786.78 | 2937.64 w deps 3833.97 | 2946.92 w deps 3846.08 | 2964.80 w deps 3869.42 | 2991.77 w deps 3904.61 | 3030.26 w deps 3954.85 | 3062.40 w deps 3996.80 | 3079.99 w deps 4019.75 | 3098.07 w deps 4043.34 | 3106.77 w deps 4054.70 | 3161.09 w deps 4125.59 | 3191.97 w deps 4165.89 | 3230.94 w deps 4216.76 | 3312.42 w deps 4323.10 | 3333.91 w deps 4351.15 | 3372.80 w deps 4401.90 | 3441.47 w deps 4491.53 | 3517.49 w deps 4590.74 | 3606.20 w deps 4706.51 |