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| Plan | Bronze Full PPO Savings 7000 OffEx | Bronze PPO 6950/0% w/HSA 5SU5 | Silver PPO 2500/35% w/HSA PrevRx 5T0V Single | Silver Full PPO Savings 2100/25% OffEx | Gold Full PPO Savings 1750/15 OffEx |
| Metal | Bronze | Bronze | Silver | Silver | Gold |
| Network | Full PPO Network | Prudent Buyer PPO | Prudent Buyer PPO | Full PPO Network | Full PPO Network |
| Deductible | $7000/$14,000 family | $6950/$13,900 family | $2000 or $2800 ($4000 family) | $2100 or $2800/$4200 family | $1750 or $2800/$3500 family |
| Coinsurance | 100% coverage for most services | 100% coverage after ded | 70% coverage for most services | 75% coverage for most services | 85% coverage for most services |
| Out of Pocket Mzx | $6900/$13,800 family | $6950/$13,900 family | $6950/$13,900 family | $6900/$7800 family | $3000/$6000 family |
| Ambulance | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Chiropractor | 100% coverage (after deductible) | 20 visits max | 20 visits max | 75% coverage after ded (20 visits max) | 85% coverage after ded (20 visits max) |
| Durable Med Equip | 100% coverage (after deductible) | 100% coverage after ded | 50% coverage (ded applies) | 50% coverage (after deductible) | 85% coverage after ded |
| Emergency Room | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | $150 copay then 75% after ded | $350 per visit then 85% cov after ded |
| Hospital | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Infertility | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Office Visit | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Specialist | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Outpatient Surgery | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Physical Therapy | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Inpatient Psych | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Outpatient Psych | 100% coverage (after deductible) | 100% coverage after ded | 65% coverage (ded applies) | 75% coverage after ded | 85% coverage after ded |
| Rx Tier 1 | 100% coverage (after deductible) | 100% coverage after ded | $20 copayment (after ded) | $20 copayment after ded | $10 copayment after ded |
| Rx Tier 2 | 100% coverage (after deductible) | 100% coverage after ded | $65 copayment (after ded) | $65 copay (after ded) | $30 copayment after ded |
| Rx Tier 3 | 100% coverage (after deductible) | 100% coverage after ded | $100 copayment (after ded) | $100 copay (after ded) | $50 copay (after ded) |
| Rx Tier 4 | 100% coverage (after deductible) | 100% coverage after ded | 70% coverage to $250 max (ded applies) | 70% coverage up to $250 per Rx after ded | 70% coverage up to $250 per Rx after ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Kristie | 1086.01 | 1131.06 | 1209.97 | 1267.71 | 1450.85 |
| Total | 1086.01 | 1131.06 | 1209.97 | 1267.71 | 1450.85 |