|  |
| Plan | Silver PPO 1750/35%/7350 |
| Metal | Silver |
| Network | Prudent Buyer PPO |
| Deductible | $1750/$3500 family |
| Coinsurance | 65% coverage for most services |
| Out of Pocket Mzx | $7700/$15,400 family |
| Ambulance | 65% coverage (ded applies) |
| Chiropractor | 50% coverage, 20 visits max (ded waived) |
| Durable Med Equip | 50% coverage (ded applies) |
| Emergency Room | $300 copay then 65% coverage (ded apples) |
| Hospital | 65% coverage (ded applies) |
| Infertility | Not covered |
| Lab & X-Ray | 65% coverage (ded applies) |
| Office Visit | $55 copayment |
| Specialist | $80 copayment |
| Outpatient Surgery | 65% coverage (ded applies) |
| Physical Therapy | 65% coverage (ded applies) |
| Inpatient Psych | 65% coverage (ded applies) |
| Outpatient Psych | $55 copayment |
| Rx Tier 1 | $5 or $20 copayment |
| Rx Tier 2 | $50 copayment ($300/$600 family Rx ded applies) |
| Rx Tier 3 | $90 copayment ($300/$600 family Rx ded applies) |
| Rx Tier 4 | 70% coverage to $250 max ($300/$600 family Rx ded applies) |
| Links | Brochure Formulary Providers |
| Jose Silva | 1346.22 fam 2607.18 |
| Lee Roy Trejo | 548.36 fam 2087.54 |
| Manuel Rodriguez Jr | 544.77 |
| Total | 2439.35 w deps 5239.49 |