Plan	Silver Full PPO 1200/35 OffEx	Silver Full PPO 750/30 OffEx	Gold Full PPO 500/30 OffEx	Gold Full PPO 0/20 OffEx
Metal	Silver	Silver	Gold	Gold
Network	Full PPO Network	Full PPO Network	Full PPO Network	Full PPO Network
Deductible	$1200/$2400 family	$750/$1500 family	$500/$1000 family	None
Coinsurance	80% coverage for most services	80% coverage for most services	80% coverage for most services	70% coverage for most services
Out of Pocket Mzx	$7800/$15,600 family	$7800/$15,600 family	$7800/$15,600 family	$7650/$15,300 family
Ambulance	80% coverage after ded	80% coverage	80% coverage after ded	70% coverage
Chiropractor	$10 per visit	80% coverage	Not covered	Not covered
Durable Med Equip	50% coverage (after deductible)	50% coverage	50% after ded	50% coverage
Emergency Room	$250 copayment (then 80% coverage) after ded	$250 copay after ded then 20%	$250 copay after ded then 20%	$250 copay then 70% coverage
Hospital	80% coverage after ded	80% coverage after ded	80% coverage (after deductible)	70% coverage
Infertility	Not covered	Not covered	Not covered	Not covered
Lab & X-Ray	$35 lab/$50 X-ray	$30 lab/$50 X-ray	$30 lab/$50 X-ray	$20 lab/$50 X-ray
Office Visit	$35 copayment	$30 copayment	$30 copayment	$20 copayment
Specialist	$50 copayment	$50 copayment	$50 copayment	$50 copayment
Outpatient Surgery	$150 copayment (then 80% coverage)	$150 copayment then 80% coverage after ded	$150 copayment (then 80% coverage)	$150 copayment (then 70% coverage)
Physical Therapy	80% coverage after ded	80% coverage after ded	80% coverage (after deductible)	70% coverage
Inpatient Psych	80% coverage after ded	80% coverage after ded	80% coverage (after deductible)	70% coverage
Outpatient Psych	$35 copayment	$30 copayment	$30 copayment	$20 copayment
Rx Tier 1	$10 copayment	$10 copayment	$15 copaymemt	$15 copayment
Rx Tier 2	$40 copayment (after $300 Rx ded)	$40 copayment (after $250 Rx ded)	$50 copayment (after $100 Rx ded)	$40 copayment
Rx Tier 3	$70 copayment (after $300 Rx ded)	$70 copayment to $250 max (after $250 Rx ded)	$80 copayment (after $100 Rx ded)	$60 copayment
Rx Tier 4	70% coverage up to $250 per Rx (after $300 Rx ded)		70% cov after $100 Rx ded up to $250 per Rx	70% coverage up to $250 per Rx
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
Tommy Smith	450.53	462.57	468.82	475.5
Brian Van Norman	450.53	462.57	468.82	475.5
Robert Brooks	450.53	462.57	468.82	475.5
William Scheruer	450.53	462.57	468.82	475.5
Total	2308.61 w deps 5189.18	2370.3 w deps 5327.88	2402.33 w deps 5399.87	2436.55 w deps 5476.75