|  | | | |
| Plan | Bronze 60 HMO 5400/60 (shop) | Silver 70 HMO 2300/65 (shop) | Gold 80 HMO 0/35 (shop) | Platinum 90 HMO 0/20 (shop) |
| Metal | Bronze | Silver | Gold | Platinum |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $5800/$11,600 family | $2300/$4600 family | None | None |
| Coinsurance | 60% coverage for most services | 55% coverage for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8850/19,700 family | $8750/17,500 family | $7700/15,400 family | $4500/$9000 family |
| Ambulance | 60% coverage (after ded) | 55% coverage (after ded) | $350 copay (after ded) | $150 copayment |
| Chiropractor | $60 copay (physciain referral) | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | $20 copay (physician referral) |
| Durable Med Equip | 60% coverage (after ded) | 55% coverage (ded applies) | 80% coverage (after ded) | 90% coverage |
| Emergency Room | 60% coverage (after ded) | 55% coverage (ded applies) | $350 copay (after ded) | $150 copay |
| Hospital | 60% coverage (after ded) | 55% coverage (ded applies) | $600 per day 1st 5 days | $250 per day 1st 5 days |
| Infertility | Optional | Optional | Optional | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) | $30 lab/$75 X-ray after ded | $30 lab/$40 X-ray | $20 lab/$30 X-ray |
| Office Visit | $60 copay (ded waived) | $65 copayment | $35 copayment | $20 copayment |
| Specialist | $95 copayment (ded applies) | $100 copayment | $60 copayment | $30 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 65% coverage (after ded) | $320 copayment | $125 copayment (per procedure) |
| Physical Therapy | $60 copayment | $55 copayment | $30 copayment | $20 copayment |
| Inpatient Psych | 60% coverage (after ded) | 55% coverage (ded applies) | $600 per day 1st 5 days | $250 per day 1st 5 days |
| Outpatient Psych | $60 copay (ded applies) | $65 copayment | $30 copayment | $20 copayment |
| Rx Tier 1 | $19 copay | $20 copay | $15 copayment | $5 copayment |
| Rx Tier 2 | 60% coverage to $500 ($450 Rx ded applies) | $100 copay (after $500 Rx ded) | $50 copayment | $20 copayment |
| Rx Tier 3 | 60% coverage to $500 ($450 Rx ded applies) | $100 copay (after $500 Rx ded) | $50 copayment | $40 copayment |
| Rx Tier 4 | 60% coverage to $500 ($450 Rx ded applies) | 80% cov $250 max (after $500 Rx ded) | 80% coverage to $250 max | 90% cov up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Marco Guglielmino | 420.9 | 462.11 | 589.31 | 617.82 |
| Michelle Lee | 435.95 | 478.63 | 610.38 | 639.91 |
| Omid Mehrage | 408.86 | 448.9 | 572.46 | 600.15 |
| Total | 1265.71 | 1389.64 | 1772.15 | 1857.88 |