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| Plan | Bronze Tandem PPO 7500/65 OffEx | Bronze PPO 6300/65 | Bronze Full PPO 6850/55 OffEx | Bronze Tandem PPO 6500/70 OffEx | Bronze Full PPO Savings 7000 OffEx | Bronze Full PPO Savings 5700/40% OffEx | Bronze Full PPO 6500/70 OffEx | Silver HDHP PPO 1500/50% | Silver PPO 2250/60 | Silver Tandem PPO 2550/70 OffEx | Silver Tandem PPO Savings 2300/25% OffEx | Silver Tandem PPO 2000/60 OffEx | Silver Full PPO Savings 2600/35% OffEx | Silver PPO 2500/55 | Silver Full PPO 2550/70 OffEx | Silver Full PPO 2350/65 OffEx | Silver Full PPO Savings 2300/25% OffEx | Silver Full PPO 2000/60 OffEx | Gold PPO 1600/0 | Gold PPO 1000/35 | Gold PPO 500/20 | Gold PPO 0/35 | Gold Tandem PPO 750/30 OffEx | Gold Tandem PPO Savings 1750/15 OffEx | Gold Tandem PPO 500/30 OffEx | Gold Tandem PPO 0/25 OffEx | Gold Full PPO 1000/35 OffEx | Gold Full PPO 750/30 OffEx | Gold PPO 350/25 | Gold Full PPO Savings 1750/15 OffEx | Gold Full PPO 500/30 OffEx | Gold Full PPO 0/25 OffEx | Platinum Tandem PPO 250/10 OffEx | Platinum Tandem PPO 0/10 OffEx | Platinum Tandem PPO 0/0 OffEx | Platinum Tandem PPO 250/10 OffEx | Platinum Full PPO 250/10 OffEx | Platinum Full PPO 0/10 OffEx | Platinum Full PPO 0/0 OffEx | Platinum Full PPO 250/10 OffEx | Platinum PPO 250/15 | Platinum PPO 0/15 |
| Metal | Bronze | Bronze | Bronze | Bronze | Bronze | Bronze | Bronze | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Silver | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum |
| Network | Tandem PPO Network | Full PPO | Full PPO Network | Tandem PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO | Full PPO | Tandem PPO Network | Tandem PPO Network | Tandem PPO Network | Full PPO Network | Full PPO | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO | Full PPO | Full PPO | Full PPO | Tandem PPO Network | Tandem PPO Network | Tandem PPO Network | Tandem PPO Network | Full PPO Network | Full PPO Network | Full PPO | Full PPO Network | Full PPO Network | Full PPO Network | Tandem PPO Network | Tandem PPO Network | Tandem PPO Network | Tandem PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO | Full PPO |
| Deductible | $7500/$15,000 family | $6300/$12,600 famly | $6850/$13,800 family | $6500/$13,000 family | $7000/$14,000 family | $5700/$11,400 family | $6500/$13,000 family | $1500/$3000 family | $2250/$4500 family | $2550/$5100 family | $2300 or $2800/$4600 family | $2000/$4000 family | $2600 or $2800/$5200 family | $2500/$5000 family | $2550/$5100 family | $2350/$4700 family | $2300 or $2800/$4600 family | $2000/$4000 family | $1600/$3200 family | $1000/$2000 family | $500/$1000 family | None | $750/$1500 family | $1750 or $2800/$3500 family | $500/$1000 family | None | $1000/$2000 family | $750/$1500 family | $350/$700 family | $1750 or $2800/$3500 family | $500/$1000 family | None | $250/$500 family | None | None | $250/$500 family | $250/$500 family | None | None | $250/$500 family | $250/$500 family | None |
| Coinsurance | 50% coverage for most services | 60% coverage for most services | 65% coverage for most services | 50% coverage for most services | 100% coverage for most services | 60% coverage for most services | 50% coverage for most services | 50% coverage for most services | 60% coverage for most services | 70% coverage for most services | 75% coverage for most services | 80% coverage for most services | 65% coverage for most services | 65% coverage for most services | 70% coverage for most services | 65% coverage for most services | 75% coverage for most services | 80% coverage for most services | 60% coverage for most services | 70% coverage for most services | 70% coverage for most services | 70% coverage for most services | 80% coverage for most services | 85% coverage for most services | 80% coverage for most services | Fixed copays for most services | 80% coverage for most services | 80% coverage for most services | 80% coverage for most services | 85% coverage for most services | 80% coverage for most services | Fixed copays for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services |
| Out of Pocket Mzx | $7500/$15,50000 family | $8200/$16,400 family | $8750/$17,500 family | $8750/$17,500 family | $7000/$14,000 family | $7000/$14,000 family | $8750/$17,500 family | $7000/$14,000 family | $9100/$18,200 family | $8750/$17,500 family | $7500//$15,000 family | $8750/$17,500 family | $7500//$15,000 family | $8600/$17,200 family | $8750/$17,500 family | $8750/$17,500 family | $7500//$15,000 family | $8750/$17,500 family | $5000/$17,000 family | $8000/$16,000 family | $8000/$16,000 family | $8100/$16,200 family | $8150/$16,100 family | $3300/$6600 family | $8500/$17,000 family | $8500/$17,000 family | $8150/$16,100 family | $8150/$16,100 family | $7800/$15,600 family | $3300/$6600 family | $8500/$17,000 family | $8500/$17,000 family | $3000/$6000 family | $4700/$9400 family | $5000/$10,000 family | $4300/$8600 family | $3000/$6000 family | $4700/$9400 family | $5000/$10,000 family | $4300/$8600 family | $3800/$7600 family | $4500/$9000 family |
| Ambulance | 50% coverage (after deductible) | 60% coverage (ded applies) | 65% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | 60% coverage after ded | 75% coverage after ded | 65% coverage (after deductible) | 65% coverage after ded | 65% coverage (ded applies) | 60% coverage after ded | 60% coverage after ded | 75% coverage after ded | 65% coverage (after deductible) | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | 80% coverage | 85% coverage after ded | 80% coverage after ded | 70% coverage | 80% coverage after ded | 80% coverage | 80% coverage (ded applies) | 85% coverage after ded | 80% coverage after ded | 70% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage (ded applies) | $150 copayment |
| Chiropractor | 50% coverage (after deductible) | Optional | $15 per visit (20 visits max) | $15 per visit (20 visits max) | 100% coverage (after deductible) | 50% coverage after ded (20 visits max) | $15 per visit (20 visits max) | Optional | Optional | $15 per visit (20 visits max) | 75% coverage after ded (20 visits max) | $15 per visit (20 visits max) | 65% coverage after ded(20 visits max) | Optional | $15 per visit (20 visits max) | $15 per visit (20 visits max) | 75% coverage after ded (20 visits max) | $15 per visit (20 visits max) | Optional | Optional | Optional | Optional | $10 per visit (20 visits max) | 85% coverage after ded (20 visits max) | $10 per visit after ded (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | Optional | 85% coverage after ded (20 visits max) | $10 per visit after ded (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | $10 per visit (20 visits max) | Optional | Optional |
| Durable Med Equip | 50% coverage (after deductible) | 60% coverage (ded applies) | 50% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | 50% coverage (after deductible) | 50% coverage after ded | 50% coverage (after deductible) | 50% coverage (after deductible) | 65% coverage (ded waived) | 50% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage after ded | 50% coverage (after deductible) | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | 50% coverage | 85% coverage after ded | 50% after ded | 50% coverage | 50% coverage (after deductible) | 50% coverage | 80% coverage (ded waived) | 85% coverage after ded | 50% after ded | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 50% coverage | 90% coverage (ded applies) | 90% coverage |
| Emergency Room | 50% coverage (after deductible) | 60% coverage (ded applies) | 50% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | $250 copayment (then 60% coverage) after ded | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | $350 per visit then 60% cov after ded | $150 per visit then 85% cov after ded | $300 per visit then 65% cov after ded | $150 copay then 65% cov after ded | 65% coverage (ded applies) | $350 per visit then 60% cov after ded | $350 per visit then 60% cov after ded | $150 per visit then 85% cov after ded | $300 per visit then 65% cov after ded | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | $250 copay after ded then 20% | $150 per visit then 85% cov after ded | $250 copay after ded then 20% | $250 copay plus 30% | $250 copayment (then 80% coverage) after ded | $250 copay after ded then 20% | 80% coverage (ded applies) | $150 per visit then 85% cov after ded | $250 copay after ded then 20% | $250 copay plus 30% | $150 copayment + 10% | $150 copay plus 10% | $250 copay then 90% coverage | $150 copayment (then 90% coverage) | $150 copayment + 10% | $150 copay plus 10% | $250 copay then 90% coverage | $150 copayment (then 90% coverage) | 90% coverage (ded applies) | $200 copayment |
| Hospital | 50% coverage (after deductible) | 60% coverage (ded applies) | 65% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | 60% coverage after ded | 85% coverage after ded | 65% coverage (after deductible) | 65% coverage after ded | 65% coverage (ded applies) | 60% coverage after ded | 60% coverage after ded | 85% coverage after ded | 65% coverage (after deductible) | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | 80% coverage after ded | 85% coverage after ded | 80% coverage (after deductible) | 70% coverage (after deductible | 80% coverage after ded | 80% coverage after ded | 80% coverage (ded applies) | 85% coverage after ded | 80% coverage (after deductible) | 70% coverage (after deductible | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage (ded applies) | 90% coverage |
| 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 | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | 50% coverage (after deductible) | Lab: $40 copay (ded waived)/X-ray $60% cov (ded applies) | 65% coverage (after deductible) | Lab: $75 copay/X-ray: $115 after ded | 100% coverage (after deductible) | 60% coverage (after deductible) | Lab: $75 copay/X-ray: $115 after ded | 50% coverage | Lab: $40 copay (ded waived)/X-ray $65 copay (ded waived) | Lab: $65 copay/X-ray: $85 | 75% coverage after ded | Lab: $45 copay/X-ray: $80 | 65% coverage after ded | Lab: $55 copay (ded waived)/X-ray $90 copay (ded waived) | Lab: $65 copay/X-ray: $85 | Lab: $65 copay/X-ray: $80 | 75% coverage after ded | Lab: $45 copay/X-ray: $80 | No charge | Lab: $30 copay/X-ray $40 copay | Lab: $30 copay (ded waived)/X-ray $40 copay(ded waived) | Lab: $30 copay/X-ray $40 copay | $30 lab/$50 X-ray | 85% coverage after ded | $30 lab/$50 X-ray | Lab $25 copay / X-ray $50 copay | $35 lab/$50 X-ray | $30 lab/$50 X-ray | Lab: $25 copay (ded waived)/X-ray $65 copay (ded waived) | 85% coverage after ded | $30 lab/$50 X-ray | Lab $25 copay / X-ray $50 copay | Lab $10 copay / X-ray $30 copay | Lab $10 copay / X-ray $25 copay | Lab $10 copay / X-ray $25 copay | Lab $15 copay / X-ray $30 copay | Lab $10 copay / X-ray $30 copay | Lab $10 copay / X-ray $25 copay | Lab $10 copay / X-ray $25 copay | Lab $15 copay / X-ray $30 copay | Lab: $30 copay (ded waived)/X-ray $30 copay (ded waived) | Lab: $15 copay/X-ray $30 copay |
| Office Visit | $65 copay (after deductible) | $65 copay 1st 3 visits then ded applies | $55 copayment (after ded) | $70 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | $70 copayment (after ded) | 50% coverage | $60 copayment | $70 copayment | 75% coverage after ded | $60 copayment | 65% coverage after ded | $55 copayment | $70 copayment | $65 copayment | 75% coverage after ded | $60 copayment | No charge | $35 copayment | $20 copayment | $35 copayment | $30 copayment | 85% coverage after ded | $30 copayment | $25 copayment | $35 copayment | $30 copayment | $25 copayment | 85% coverage after ded | $30 copayment | $25 copayment | $10 copayment | $10 copayment | No charge | $15 copayment | $10 copayment | $10 copayment | No charge | $15 copayment | $15 copayment | $15 copayment |
| Specialist | 50% coverage (after deductible) | $95 copay 1st 3 visits then ded applies | $75 copayment (after ded) | $80 copay (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | $80 copay (after ded) | 50% coverage | $85 copayment | $80 copayment | 75% coverage after ded | $80 copayment | 65% coverage after ded | $90 copayment | $80 copayment | $80 copayment | 75% coverage after ded | $80 copayment | $75 copayment | $55 copayment | $40 copayment | $55 copayment | $55 copayment | 85% coverage after ded | $55 copayment | $50 copayment | $55 copayment | $55 copayment | $50 copayment | 85% coverage after ded | $55 copayment | $50 copayment | $10 copayment | $30 copayment | $45 copayment | $30 copayment | $10 copayment | $30 copayment | $45 copayment | $30 copayment | $30 copayment | $30 copayment |
| Outpatient Surgery | 50% coverage (after deductible) | 60% coverage (ded applies) | 65% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | 60% coverage after ded | 75% coverage after ded | 65% coverage (after deductible) | $150 copayment (then 65% coverage) after ded | 65% coverage (ded applies) | 60% coverage after ded | $250 then 60% cov after ded | 75% coverage after ded | 65% coverage (after deductible) | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | $150 copayment then 80% coverage after ded | 85% coverage after ded | $150 copayment (then 80% coverage) | 70% coverage | 80% coverage after ded | $150 copayment then 80% coverage after ded | 80% coverage (ded waived) | 85% coverage after ded | $150 copayment (then 80% coverage) | 70% coverage | $100 copayment (then 90% coverage) | $100 copayment (then 90% coverage) | $100 copay then 90% coverage | $100 copayment (then 90% coverage) | $100 copayment (then 90% coverage) | $100 copayment (then 90% coverage) | $100 copay then 90% coverage | $100 copayment (then 90% coverage) | 90% coverage (ded applies) | 90% coverage |
| Physical Therapy | 50% coverage (after deductible) | $65 copayment | $55 copayment after ded | $70 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | $70 copayment (after ded) | 50% coverage | $60 copayment | 60% coverage after ded | 75% coverage after ded | $60 copayment | 65% coverage after ded | $55 copayment | 60% coverage after ded | 60% coverage after ded | 75% coverage after ded | $60 copayment | No charge | $35 copayment | $20 copayment | $35 copayment | 80% coverage after ded | 85% coverage after ded | 80% coverage (after deductible) | 70% coverage | 80% coverage after ded | 80% coverage after ded | $25 copayment | 85% coverage after ded | 80% coverage (after deductible) | 70% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | $15 copayment | $15 copayment |
| Inpatient Psych | 50% coverage (after deductible) | 60% coverage (ded applies) | 65% coverage (after deductible) | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage | 60% coverage (ded applies) | 60% coverage after ded | 75% coverage after ded | 65% coverage (after deductible) | 65% coverage after ded | 65% coverage (ded applies) | 60% coverage after ded | 60% coverage after ded | 75% coverage after ded | 65% coverage (after deductible) | 60% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage | 80% coverage after ded | 85% coverage after ded | 80% coverage (after deductible) | 80% coverage (after deductible | 80% coverage after ded | 80% coverage after ded | 80% coverage (ded applies) | 85% coverage after ded | 80% coverage (after deductible) | 80% coverage (after deductible | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage | 90% coverage (ded applies) | 90% coverage |
| Outpatient Psych | $65 copay (after deductible) | $95 copay 1st 3 visits then ded applies | $55 copayment (after ded) | $70 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | $70 copayment (after ded) | 50% coverage | $60 copayment | $70 copayment | 75% coverage after ded | $60 copayment | 65% coverage after ded | $55 copayment | $70 copayment | $65 copayment | 75% coverage after ded | $60 copayment | No charge | $35 copayment | $20 copayment | $30 copayment | $30 copayment | 85% coverage after ded | $30 copayment | $25 copayment | $35 copayment | $30 copayment | $25 copayment | 85% coverage after ded | $30 copayment | $25 copayment | $10 copayment | $10 copayment | No charge | $10 copayment | $10 copayment | $10 copayment | No charge | $10 copayment | $15 copayment | $15 copayment |
| Rx Tier 1 | $20 copay | $18 copay after $500 Rx ded | $20 copay | $20 copay | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | $20 copay | $20 copay after med ded | $20 copayment | $25 copayment | $25 copayment after ded | $25 copayment | 65% cov up to $250 per Rx after ded | $20 copayment | $25 copayment | $20 copayment | $25 copayment after ded | $25 copayment | No charge | $15 copayment | $15 copayment | $15 copayment | $10 copayment | $10 copayment after ded | $15 copaymemt | $15 copayment | $10 copayment | $10 copayment | $15 copayment | $10 copayment after ded | $15 copaymemt | $15 copayment | $10 copayment | $5 copayment | No charge | $5 copayment | $10 copayment | $5 copayment | No charge | $5 copayment | $10 copayment | $10 copayment |
| Rx Tier 2 | 50% coverage up to $250 per Rx after med ded | 60% cov after $500 Rx ded | $65 copay (after $650 Rx ded) | $130 copay (after $300 Rx ded) | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | $130 copay (after $300 Rx ded) | $70 copay after med ded | $65 copayment after $350 Rx ded | $75 copayment (after $300 Rx ded) | $70 copayment after ded | $80 copayment (after $350 Rx ded) | 65% cov up to $250 per Rx after ded | $75 copayment after $300 Rx ded | $75 copayment (after $300 Rx ded) | $50 copayment | $70 copayment after ded | $80 copayment (after $350 Rx ded) | $50 copay after $300 Rx ded | $40 copay after $250 Rx ded | $40 copay after $250 Rx ded | $40 copayment | $40 copayment (after $250 Rx ded) | $30 copayment after ded | $50 copayment (after $100 Rx ded) | $45 copayment | $40 copayment (after $300 Rx ded) | $40 copayment (after $250 Rx ded) | $50 copayment | $30 copayment after ded | $50 copayment (after $100 Rx ded) | $45 copayment | $25 copayment | $30 copayment | $30 copayment | $30 copayment | $25 copayment | $30 copayment | $30 copayment | $30 copayment | $35 copayment | $25 copayment |
| Rx Tier 3 | 50% coverage up to $250 per Rx after med ded | 60% cov after $500 Rx ded | $90 copay (after $650 Rx ded) | $160 copay (after $300 Rx ded) | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | $160 copay (after $300 Rx ded) | $100 copay after med ded | $85 copayment ($350 Rx ded applies) | $115 copayment (after $300 Rx ded) | $100 copay (after ded) | $115 copayment (after $350 Rx ded) | 65% cov up to $250 per Rx after ded | $105 copayment ($300 Rx ded applies) | $115 copayment (after $300 Rx ded) | $115 copayment (after $300 Rx ded) | $100 copay (after ded) | $115 copayment (after $350 Rx ded) | $90 copay after $300 Rx ded | $70 copay after $250 Rx ded | $70 copay after $250 Rx ded | $70 copayment | $70 copayment | $50 copay (after ded) | $80 copayment (after $100 Rx ded) | $60 copayment | $70 copayment (after $300 Rx ded) | $70 copayment | $80 copayment | $50 copay (after ded) | $80 copayment (after $100 Rx ded) | $60 copayment | $40 copayment | $50 copayment | $50 copayment | $50 copayment | $40 copayment | $50 copayment | $50 copayment | $50 copayment | $60 copayment | $40 copayment |
| Rx Tier 4 | 50% coverage up to $500 per Rx after med ded | 60% cov up to $500 after $500 Rx ded | 70% coverage up to $500 per Rx after $650 Rx ded | 50% coverage up to $1500 per Rx after $300 Rx ded | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | 50% coverage up to $1500 per Rx after $300 Rx ded | 50% (after med ded) | 60% coverage (up to $300 after $350 Rx ded) | 60% coverage up to $500 per Rx (after $300 Rx ded) | 70% coverage up to $250 per Rx after ded | 70% coverage up to $250 per Rx (after $350 Rx ded) | 65% cov up to $250 per Rx after ded | 70% coverage (up to $250 after $300 Rx ded) | 60% coverage up to $500 per Rx (after $300 Rx ded) | 60% coverage up to $250 per Rx (after $300 Rx ded) | 70% coverage up to $250 per Rx after ded | 70% coverage up to $250 per Rx (after $350 Rx ded) | 60% coverage (up to $300 per Rx after Rx ded) | 70% coverage (up to $250 per Rx after Rx ded) | 70% coverage (up to $250 per Rx after $250 Rx ded) | 70% cov ($250 max per 30 day script) | 70% cov after $100 Rx ded up to $250 per Rx | 70% coverage up to $250 per Rx after ded | 70% cov after $100 Rx ded up to $250 per Rx | 70% coverage up to $250 per Rx | 70% coverage up to $250 per Rx (after $300 Rx ded) | 70% cov after $100 Rx ded up to $250 per Rx | 80% coverage ($250 max per 30 day script) | 70% coverage up to $250 per Rx after ded | 70% cov after $100 Rx ded up to $250 per Rx | 70% coverage up to $250 per Rx | 80% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 80% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 70% coverage up to $250 per Rx | 90% coverage (up to $250 per 30 day script) | 90% cov ($250 max per 30 day script) |
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| Ana Lepe | 861.83 | 901.27 | 929.65 | 929.76 | 933.4 | 939.42 | 965.18 | 969.88 | 970.61 | 992.46 | 1010.97 | 1014.98 | 1016.28 | 1025.59 | 1030.99 | 1047.36 | 1049.91 | 1054.74 | 1094.28 | 1102.4 | 1146.12 | 1161.1 | 1165.99 | 1175.05 | 1178.61 | 1185.86 | 1192.29 | 1213.62 | 1217.69 | 1221.11 | 1226.67 | 1234.44 | 1335.21 | 1363.87 | 1374.45 | 1390.03 | 1391.41 | 1421.59 | 1431.17 | 1448.27 | 1519.87 | 1552.92 |
| Daniel Lepe | 368.04 | 384.88 | 397 | 397.05 | 398.6 | 401.18 | 412.18 | 414.18 | 414.49 | 423.82 | 431.73 | 433.44 | 434 | 437.97 | 440.28 | 447.27 | 448.36 | 450.42 | 467.31 | 470.77 | 489.45 | 495.84 | 497.93 | 501.8 | 503.32 | 506.41 | 509.16 | 518.27 | 520.01 | 521.47 | 523.84 | 527.16 | 570.19 | 582.43 | 586.95 | 593.61 | 594.2 | 607.08 | 611.18 | 618.48 | 649.05 | 663.17 |
| Jaime Lepe | 395.67 fam 1509.96 | 413.77 fam 1579.04 | 426.8 fam 1628.77 | 426.85 fam 1628.96 | 428.52 fam 1635.34 | 431.29 fam 1645.89 | 443.11 fam 1691.01 | 445.27 fam 1699.25 | 445.61 fam 1700.53 | 455.64 fam 1738.82 | 464.14 fam 1771.25 | 465.98 fam 1778.27 | 466.58 fam 1780.56 | 470.85 fam 1796.87 | 473.33 fam 1806.32 | 480.84 fam 1834.99 | 482.02 fam 1839.48 | 484.23 fam 1847.94 | 502.39 fam 1917.21 | 506.11 fam 1931.43 | 526.19 fam 2008.04 | 533.06 fam 2034.28 | 535.31 fam 2042.85 | 539.47 fam 2058.72 | 541.1 fam 2064.95 | 544.43 fam 2077.66 | 547.38 fam 2088.92 | 557.17 fam 2126.29 | 559.04 fam 2133.43 | 560.61 fam 2139.42 | 563.17 fam 2149.16 | 566.73 fam 2162.77 | 612.99 fam 2339.31 | 626.15 fam 2389.53 | 631.01 fam 2408.08 | 638.16 fam 2435.36 | 638.8 fam 2437.79 | 652.65 fam 2490.66 | 657.05 fam 2507.45 | 664.9 fam 2537.41 | 697.77 fam 2662.84 | 712.95 fam 2720.77 |
| Total | 1625.54 w deps 2739.83 | 1699.92 w deps 2865.19 | 1753.45 w deps 2955.42 | 1753.66 w deps 2955.77 | 1760.52 w deps 2967.34 | 1771.89 w deps 2986.49 | 1820.47 w deps 3068.37 | 1829.33 w deps 3083.31 | 1830.71 w deps 3085.63 | 1871.92 w deps 3155.10 | 1906.84 w deps 3213.95 | 1914.40 w deps 3226.69 | 1916.86 w deps 3230.84 | 1934.41 w deps 3260.43 | 1944.60 w deps 3277.59 | 1975.47 w deps 3329.62 | 1980.29 w deps 3337.75 | 1989.39 w deps 3353.10 | 2063.98 w deps 3478.80 | 2079.28 w deps 3504.60 | 2161.76 w deps 3643.61 | 2190.00 w deps 3691.22 | 2199.23 w deps 3706.77 | 2216.32 w deps 3735.57 | 2223.03 w deps 3746.88 | 2236.70 w deps 3769.93 | 2248.83 w deps 3790.37 | 2289.06 w deps 3858.18 | 2296.74 w deps 3871.13 | 2303.19 w deps 3882.00 | 2313.68 w deps 3899.67 | 2328.33 w deps 3924.37 | 2518.39 w deps 4244.71 | 2572.45 w deps 4335.83 | 2592.41 w deps 4369.48 | 2621.80 w deps 4419.00 | 2624.41 w deps 4423.40 | 2681.32 w deps 4519.33 | 2699.40 w deps 4549.80 | 2731.65 w deps 4604.16 | 2866.69 w deps 4831.76 | 2929.04 w deps 4936.86 |