|  | |
| Plan | Bronze MS86 HMO | Silver MS84 HMO |
| Metal | Bronze | Silver |
| Network | Sutter HMO | Sutter HMO |
| Deductible | $6300 / $12,600 family | $2500 / $5000 family |
| Coinsurance | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8200/$16,400 family | $8750 / $17,500 family |
| Ambulance | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Chiropractor | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Emergency Room | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Hospital | 60% coverage (after deductible) | 60% coverage (after deductible) |
| Infertility | Optional | Optional |
| Lab & X-Ray | $40 lab / X-ray 60% cov after ded | $55 lab / $90 X-ray |
| Office Visit | $65 copay 1st 3 visits then ded applies | $55 per visit |
| Specialist | $95 copay 1st 3 visits then ded applies | $90 per visit |
| Outpatient Surgery | 60% coverage (after deductible) | 65% coverage (after deductible) |
| Physical Therapy | $65 copay | $55 per visit |
| Inpatient Psych | 60% coverage (after deductible) | 60% coverage (after deductible) |
| Outpatient Psych | $65 copay 1st 3 visits then ded applies | $55 per visit |
| Rx Tier 1 | $18 copay after $500 Rx ded | $19 copayment |
| Rx Tier 2 | 60% coverage up to $500 after $500 Rx ded | $85 copay after $300 Rx ded |
| Rx Tier 3 | 60% coverage up to $500 after $500 Rx ded | $110 copay after $300 Rx ded |
| Rx Tier 4 | 60% coverage up to $500 after $500 Rx ded | 70% coverage up to $250 after $300 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Tim Mathewson | 375.99 fam 1127.42 | 468.41 fam 1404.57 |
| Total | 375.99 w deps 1127.42 | 468.41 w deps 1404.57 |