|  | | |
| Plan | Bronze MS86 HMO | Bronze SD48 HDHP HMO | Silver MS84 HMO |
| Metal | Bronze | Bronze | Silver |
| Network | Sutter HMO | Sutter HMO | Sutter HMO |
| Deductible | $6300 / $12,600 family | $7000/$14,000 family | $2500 / $5000 family |
| Coinsurance | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8200/$16,400 family | $7000/$14,000 family | $8750 / $17,500 family |
| Ambulance | 60% coverage (after deductible) | 100% coverage (after deductible) | 70% coverage (after deductible) |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after deductible) | 100% coverage (after deductible) | 70% coverage (after deductible) |
| Emergency Room | 60% coverage (after deductible) | 100% coverage (after deductible) | 70% coverage (after deductible) |
| Hospital | 60% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | $40 lab / X-ray 60% cov after ded | 100% coverage (after deductible) | $55 lab / $90 X-ray |
| Office Visit | $65 copay 1st 3 visits then ded applies | 100% coverage (after deductible) | $55 per visit |
| Specialist | $95 copay 1st 3 visits then ded applies | 100% coverage (after deductible) | $90 per visit |
| Outpatient Surgery | 60% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Physical Therapy | $65 copay | 100% coverage (after deductible) | $55 per visit |
| Inpatient Psych | 60% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) |
| Outpatient Psych | $65 copay 1st 3 visits then ded applies | 100% coverage (after deductible) | $55 per visit |
| Rx Tier 1 | $18 copay after $500 Rx ded | 100% coverage (after deductible) | $19 copayment |
| Rx Tier 2 | 60% coverage up to $500 after $500 Rx ded | 100% coverage (after deductible) | $85 copay after $300 Rx ded |
| Rx Tier 3 | 60% coverage up to $500 after $500 Rx ded | 100% coverage (after deductible) | $110 copay after $300 Rx ded |
| Rx Tier 4 | 60% coverage up to $500 after $500 Rx ded | 100% coverage (after deductible) | 70% coverage up to $250 after $300 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Diego | 295.51 | 303.04 | 373.41 |
| Tim | 345.99 fam 1057.86 | 354.81 fam 1084.84 | 437.2 fam 1336.73 |
| Total | 641.50 w deps 1353.37 | 657.85 w deps 1387.88 | 810.61 w deps 1710.14 |