|  |
| Plan | Gateway 5020 Silver 70 HMO |
| Metal | Silver |
| Network | HMO Network |
| Deductible | $2000/$4000 family |
| Coinsurance | Fixed copays for most services |
| Out of Pocket Mzx | $7800/$15600 family |
| Ambulance | No Charge |
| Chiropractor | $15 copayment (20 visits max) |
| Durable Med Equip | 80% coverage |
| Emergency Room | 70% coverage (after deductible) |
| Hospital | 70% coverage (ded applies) |
| Infertility | Optional |
| Lab & X-Ray | Lab $50/X-ray $80 copayment |
| Office Visit | $50 per visit |
| Specialist | $50 per visit |
| Outpatient Surgery | $500 copayment (ded applies) |
| Physical Therapy | $50 per visit |
| Inpatient Psych | 70% coverage (ded applies) |
| Outpatient Psych | $50 per visit |
| Rx Tier 1 | $25 copayment |
| Rx Tier 2 | $50 copayment (after $500 Rx ded) |
| Rx Tier 3 | $75 copayment (after $500 Rx ded) |
| Rx Tier 4 | 70% coverage up to $250 (after $500 Rx ded) |
| Links | Brochure Formulary Providers |
| Gina | 740 |
| Steven Banta | 460.02 |
| Total | 1200.02 |