|  |
| Plan | Bronze PPO 70/6600/35% (6RFV) |
| Metal | Bronze |
| Network | Prudent Buyer PPO |
| Deductible | $6600/$13,200 family |
| Coinsurance | 65% coverage for most services |
| Out of Pocket Mzx | $8700/$17,400 family |
| Ambulance | 65% coverage (ded applies) |
| Chiropractor | 20 visits max (other limitations apply) |
| Durable Med Equip | 50% coverage (ded applies) |
| Emergency Room | $250 copay then 65% coverage (ded apples) |
| Hospital | 65% coverage (ded applies) |
| Infertility | Optional |
| Lab & X-Ray | 60% coverage (ded applies) |
| Office Visit | $70 copayment |
| Specialist | $85 copayment |
| Outpatient Surgery | $200 copay then 60% coverage (ded applies) |
| Physical Therapy | 65% coverage (ded applies) |
| Inpatient Psych | 65% coverage (ded applies) |
| Outpatient Psych | $70 copayment |
| Rx Tier 1 | $20 copayment |
| Rx Tier 2 | $80 copay (med ded applies) |
| Rx Tier 3 | $120 copayment (med ded applies) |
| Rx Tier 4 | 70% coverage to $400 max (med ded applies) |
| Links | Brochure Formulary Providers |
| Charles Husome | 998.78 |
| Rachel | 479.15 |
| Total | 1477.93 |