|  | |
| Plan | Bronze 60 HMO 6300/65 (shop) | Silver 70 HMO 2250/55 (shop) |
| Metal | Bronze | Silver |
| Network | Kaiser Permanente | Kaiser Permanente |
| Deductible | $6300/$12,600 family | $2250/$4500 family |
| Coinsurance | 60% coverage for most services | 70% coverage for most services |
| Out of Pocket Mzx | $8200/16,400 family | $8200/16,400 family |
| Ambulance | 60% coverage (after ded) | 70% coverage (ded applies) |
| Chiropractor | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | 70% coverage |
| Emergency Room | 60% coverage (after ded) | 70% coverage (ded applies) |
| Hospital | 60% coverage (after ded) | 70% coverage (ded applies) |
| Infertility | Optional | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) | $55 lab/$90 X-ray |
| Office Visit | $65 copayment first 3 visits then deductible applies | $55 copayment |
| Specialist | $95 copayment first 3 visits then deductible applies | $90 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 70% coverage (ded applies) |
| Physical Therapy | $65 copayment | $55 copayment |
| Inpatient Psych | 60% coverage (after ded) | 70% coverage (ded applies) |
| Outpatient Psych | $65 copayment first 3 visits then deductible applies | $55 copayment |
| Rx Tier 1 | $500 Rx ded then $18 ded per Rx | $500 Rx ded then $17 ded per Rx |
| Rx Tier 2 | 60% coverage to $500 ($500 Rx ded applies) | $65 copay (after $300 Rx ded) |
| Rx Tier 3 | 60% coverage to $500 ($500 Rx ded applies) | $65 copay (after $300 Rx ded) |
| Rx Tier 4 | 60% coverage to $500 ($500 Rx ded applies) | 80% cov $250 max ben (after $300 Rx ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Carole Detherage | 634.48 | 738.98 |
| Humberto Ramirez | 336.69 fam 675.55 | 392.14 fam 786.81 |
| Leopoldo Pedraza | 463.96 | 540.38 |
| Total | 1435.13 w deps 1773.99 | 1671.50 w deps 2066.17 |