|  |  |
| Plan | Silver PPO 2250/60 | Silver Full PPO 2550/70 OffEx |
| Metal | Silver | Silver |
| Network | Full PPO | Full PPO Network |
| Deductible | $2250/$4500 family | $2550/$5100 family |
| Coinsurance | 60% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $9100/$18,200 family | $8750/$17,500 family |
| Ambulance | 60% coverage (ded applies) | 60% coverage after ded |
| Chiropractor | Optional | $15 per visit (20 visits max) |
| Durable Med Equip | 60% coverage (ded applies) | 50% coverage (after deductible) |
| Emergency Room | 60% coverage (ded applies) | $350 copay then 60% cov after ded |
| Hospital | 60% coverage (ded applies) | 60% coverage after ded |
| Infertility | Optional | Optional |
| Lab & X-Ray | Lab: $40 copay (ded waived)/X-ray $65 copay (ded waived) | Lab: $65 copay/X-ray: $85 |
| Office Visit | $60 copayment | $70 copayment |
| Specialist | $85 copayment | $80 copayment |
| Outpatient Surgery | 60% coverage (ded applies) | 60% coverage after ded |
| Physical Therapy | $60 copayment | 60% coverage after ded |
| Inpatient Psych | 60% coverage (ded applies) | $70 copayment |
| Outpatient Psych | $60 copayment | 60% coverage after ded |
| Rx Tier 1 | $20 copayment | $25 copayment |
| Rx Tier 2 | $65 copayment after $350 Rx ded | $75 copayment (after $300 Rx ded) |
| Rx Tier 3 | $85 copayment ($350 Rx ded applies) | $115 copayment (after $300 Rx ded) |
| Rx Tier 4 | 60% coverage (up to $300 after $350 Rx ded) | 60% coverage up to $500 per Rx (after $300 Rx ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Jack | 1090.53 fam 2266.52 | 1272.61 fam 2644.95 |
| Marie | 977.41 | 1140.6 |
| Total | 2067.94 w deps 3243.93 | 2413.21 w deps 3785.55 |