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| Plan | Silver Select PPO 2100/30% w/HSA PrevRx (Single – 6RJ2, Family – 6RHT) | Gold Select HMO 35/500/20% (6RK2) | Gold Select PPO 5/1500/30% (6RJD) | Gold PPO 5/1500/30% (6RK1) | Gold Select PPO 35/500/25% (6RH7) | Gold Select PPO 30/750/20% (6RFP) | Gold PPO 35/1000/20% (6RH1) | Gold Priority Select HMO 35/500/20% RxD (8NAN) | Gold Select PPO 25/30% (6RGD) | Gold PPO 35/500/25% (6RGV) | Gold PPO 30/500/20% RxD (8NCE) | Gold PPO 30/750/20% (6RGS) | Gold Select PPO 30/500/20% (6RHX) | Gold Select PPO 25/30% (8NAQ) | Gold PPO 35/1000/20% WH (6RK3) | Gold PPO 35/500/25% WH (6RJA) | Gold PPO 30/500/20% RxD (8NAP) | Gold PPO 30/500/20% (6RG9) | Gold PPO 25/30% RxD (8NAG) | Platinum Select PPO 5/200/15% (6RJT) | Platinum PPO 5/200/15% (6RJP) | Platinum Select PPO 15/250/10% (6RHD) | Platinum PPO 5/200/15% WH (6RFQ) | Platinum PPO 15/250/10% (6RG6) | Platinum Select PPO 15/40/10% (6RHY) | Platinum PPO 15/40/10% (6RH4) | Platinum Select PPO 15/10% (6RJJ) |
| Metal | Silver | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Gold | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum | Platinum |
| Network | Select PPO | Select HMO | Select PPO | Prudent Buyer PPO | Select PPO | Select PPO | Prudent Buyer PPO | Priority Select HMO | Select PPO | Prudent Buyer PPO | Prudent Buyer PPO | Prudent Buyer PPO | Select PPO | Select PPO | Prudent Buyer PPO | Prudent Buyer PPO | Prudent Buyer PPO | Prudent Buyer PPO | Prudent Buyer PPO | Select PPO | Prudent Buyer PPO | Select PPO | Prudent Buyer PPO | Prudent Buyer PPO | Select PPO | Prudent Buyer PPO | Select PPO |
| Deductible | $2100 or $3000 ($4200 family) | $500/$1500 family | $1500/$3000 family | $1500/$3000 family | $500/$1500 family | $750/$2250 family | $1000/$3000 family | $500/$1500 family | None | $500/$1500 family | $500/$1500 family | $750/$2250 family | $500/$1500 family | None | $1000/$3000 family | $500/$1500 family | $500/$1500 family | $500/$1500 family | None | $200/$600 family | $200/$600 family | $250/$750 family | $200/$600 family | $250/$750 family | None | None | $150 copayment |
| Coinsurance | 70% coverage for most services | 80% coverate for most services | 70% coverage for most services | 70% coverage for most services | 75% coverage for most services | 80% coverage for most services | 80% coverage for most services | 80% coverate for most services | 70% coverage for most services | 75% coverage for most services | 80% coverage for most services | 80% coverage for most services | 80% coverage for most services | 70% coverage for most services | 80% coverage for most services | 75% coverage for most services | 80% coverage for most services | 80% coverage for most services | 70% coverage for most services | 85% coverage for most services | 85% coverage for most services | 90% coverage for most services | 85% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services | 90% coverage for most services |
| Out of Pocket Mzx | $7200/$14,200 family | $8450/$16,900 family | $8300/$16,600 family | $8300/$16,600 family | $8200/$16,400 family | $8200/$16,400 family | $8200/$16,400 family | $8450/$16,900 family | $8200/$16,400 family | $8200/$16,400 family | $7900/$15,800 family | $8200/$16,400 family | $7900/$15,800 family | $8200/$16,400 family | $8200/$16,400 family | $8200/$16,400 family | $7900/$15,800 family | $7900/$15,800 family | $8200/$16,400 family | $3800/$7600 family | $3800/$7600 family | $3800/$7600 family | $3800/$7600 family | $3800/$7600 family | $3800/$7600 family | $3800/$7600 family | $4500/$9000 family |
| Ambulance | 70% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 80% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 85% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 90% coverage | 90% coverage | 90% coverage |
| Chiropractor | 20 visits max (other limitations apply) | 30 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 30 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | 20 visits max (other limitations apply) | Not covered |
| Durable Med Equip | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 80% coverage (ded applies) | 50% coverage (ded applies) | 80% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage (ded applies) | 50% coverage | 50% coverage | 50% coverage (ded applies) |
| Emergency Room | 70% coverage (ded applies) | $300 copay then 80% coverage (ded apples) | $250 copay then 70% coverage | $250 copay then 70% coverage | $250 copay then 75% coverage | $250 copay then 80% coverage | $250 copay then 80% coverage (ded applies) | $300 copay then 80% coverage (ded apples) | $250 copay then 70% coverage | $250 copay then 75% coverage | $250 copay then 80% coverage | $250 copay then 80% coverage | $250 copay then 80% coverage | $250 copay then 70% coverage | $250 copay then 80% coverage (ded applies) | $250 copay then 75% coverage | $250 copay then 80% coverage | $250 copay then 80% coverage | $250 copay then 70% coverage | $250 copay then 85% coverage | $250 copay then 85% coverage | $225 copay then 90% coverage | $250 copay then 85% coverage | $225 copay then 90% coverage | $200 copa then 90% coverage | $200 copa then 90% coverage | $200 copay then 90% coverage |
| Hospital | 70% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 80% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 85% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 90% coverage | 90% coverage | 90% coverage (ded applies) |
| Infertility | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | 70% coverage (ded applies) | $15 lab/$350 X-ray copayment | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/$350 X-ray copayment | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $15 lab/X-ray $15 | $10 lab/X-ray $10 copay | $10 lab/X-ray $10 copay | $10 lab/X-ray $10 | $10 lab/X-ray $10 copay | $10 lab/X-ray $10 | $10 lab/$10 X-ray copayment | $10 lab/$10 X-ray copayment | $15 lab/$30 X-ray copayment |
| Office Visit | 70% coverage (ded applies) | $35 copayment | $5 copayment | $5 copayment | $35 copayment | $30 copayment | $35 copayment | $35 copayment | $25 copayment | $35 copayment | $30 copayment | $30 copayment | $30 copayment | $25 copayment | $35 copayment | $35 copayment | $30 copayment | $30 copayment | $25 copayment | $5 copayment | $5 copayment | $15 copayment | $5 copayment | $15 copayment | $15 copayment | $15 copayment | $15 copayment |
| Specialist | 70% coverage (ded applies) | $55 copayment | $65 copayment | $65 copayment | $65 copayment | $55 copayment | $60 copayment | $55 copayment | $50 copayment | $65 copayment | $60 copayment | $55 copayment | $60 copayment | $50 copayment | $60 copayment | $65 copayment | $60 copayment | $60 copayment | $50 copayment | $45 copayment | $45 copayment | $30 copayment | $45 copayment | $30 copayment | $40 copayment | $40 copayment | $30 copayment |
| Outpatient Surgery | $200 copay then 80% coverage | 80% coverage (ded applies) | $200 copay then 70% coverage | $200 copay then 70% coverage | $200 copay then 75% coverage | $200 copay then 80% coverage | $200 copay then 80% coverage | 80% coverage (ded applies) | $200 copay then 70% coverage | $200 copay then 75% coverage | $200 copay then 80% coverage | $200 copay then 80% coverage | $200 copay then 80% coverage | $200 copay then 70% coverage | $200 copay then 80% coverage | $200 copay then 75% coverage | $200 copay then 80% coverage | $200 copay then 80% coverage | $200 copay then 70% coverage | $200 copay then 85% coverage | $200 copay then 85% coverage | $200 copay then 90% coverage | $200 copay then 85% coverage | $200 copay then 90% coverage | $150 copay then 90% coverage | $150 copay then 90% coverage | 90% coverage (ded applies) |
| Physical Therapy | 70% coverage (ded applies) | $35 copayment | $5 copayment | $5 copayment | $35 copayment | $30 copayment | $35 copayment | $35 copayment | $25 copayment | $35 copayment | $30 copayment | $30 copayment | $30 copayment | $25 copayment | $35 copayment | $35 copayment | $30 copayment | $30 copayment | $25 copayment | $5 copayment | $5 copayment | $15 copayment | $5 copayment | $15 copayment | $15 copayment | $15 copayment | $15 copayment |
| Inpatient Psych | 70% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage (ded applies) | 70% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 80% coverage (ded applies) | 75% coverage (ded applies) | 80% coverage (ded applies) | 80% coverage (ded applies) | 70% coverage | 85% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 85% coverage (ded applies) | 90% coverage (ded applies) | 90% coverage | 90% coverage | 90% coverage |
| Outpatient Psych | 70% coverage (ded applies) | $35 copayment | $5 copayment | $5 copayment | $35 copayment | $30 copayment | $35 copayment | $35 copayment | $25 copayment | $35 copayment | $30 copayment | $30 copayment | $30 copayment | $25 copayment | $35 copayment | $35 copayment | $30 copayment | $30 copayment | $25 copayment | $5 copayment | $5 copayment | $15 copayment | $5 copayment | $15 copayment | $15 copayment | $15 copayment | $15 copayment |
| Rx Tier 1 | $15 copayment (after medical ded) | $10 copayment | $5 copayment | $5 copayment | $10 copayment | $10 copayment | $5 copayment | $10 copayment | $10 copayment | $10 copayment | $10 copayment | $10 copayment | $10 copayment | $10 copayment | $5 copayment | $10 copayment | $10 copayment | $10 copayment | $10 copayment | $5 copayment | $5 copayment | $5 copayment | $5 copayment | $5 copayment | $5 copayment | $5 copayment | $10 copayment |
| Rx Tier 2 | $70 copayment (after medical ded) | $50 copay (after $150 Rx ded) | $60 copay (after $300 Rx ded) | $60 copay (after $300 Rx ded) | $50 copay after $250 Rx ded | $50 copay (after $250 Rx ded) | $60 copay after $300 Rx ded | $50 copay (after $150 Rx ded) | $50 copay (after $150 Rx ded) | $50 copay after $250 Rx ded | $50 copay (after $150 Rx ded) | $50 copay (after $250 Rx ded) | $50 copay (after $150 Rx ded) | $50 copay (after $150 Rx ded) | $60 copay after $300 Rx ded | $50 copay after $250 Rx ded | $50 copay (after $150 Rx ded) | $50 copay (after $150 Rx ded) | $50 copay (after $150 Rx ded) | $30 copayment | $30 copayment | $30 copayment | $30 copayment | $30 copayment | $30 copayment | $30 copayment | $25 copayment |
| Rx Tier 3 | $110 copayment (after medical ded) | $90 copay (after $150 Rx ded) | $110 copay (after $300 Rx ded) | $110 copay (after $300 Rx ded) | $90 copay (after $250 Rx ded) | $90 copay (after $250 Rx ded) | $110 copay after $300 Rx ded | $90 copay (after $150 Rx ded) | $90 copay (after $150 Rx ded) | $90 copay (after $250 Rx ded) | $90 copay (after $150 Rx ded) | $90 copay (after $250 Rx ded) | $90 copay (after $150 Rx ded) | $90 copay (after $150 Rx ded) | $110 copay after $300 Rx ded | $90 copay (after $250 Rx ded) | $90 copay (after $150 Rx ded) | $90 copay (after $150 Rx ded) | $90 copay (after $150 Rx ded) | $50 copayment | $50 copayment | $50 copayment | $50 copayment | $50 copayment | $50 copayment | $50 copayment | $40 copayment |
| Rx Tier 4 | 70% coverage to $250 (medical ded applies) | 70% coverage to $250 max ($150 Rx ded applies) | 70% coverage to $250 after $300 Rx ded | 70% coverage to $250 after $300 Rx ded | 70% coverage to $250 max after $250 Rx ded | 70% coverage to $250 after $250 Rx ded | 70% coverage to $250 max after $300 Rx ded | 70% coverage to $250 max ($150 Rx ded applies) | 70% coverage to $250 after $150 Rx ded | 70% coverage to $250 max after $250 Rx ded | 70% coverage to $250 max (after $150 Rx ded) | 70% coverage to $250 after $250 Rx ded | 70% coverage to $250 max (after $150 Rx ded) | 70% coverage to $250 after $150 Rx ded | 70% coverage to $250 max after $300 Rx ded | 70% coverage to $250 max after $250 Rx ded | 70% coverage to $250 max (after $150 Rx ded) | 70% coverage to $250 max (after $150 Rx ded) | 70% coverage to $250 after $150 Rx ded | 70% coverage to $250 max | 70% coverage to $250 max | 70% coverage to $250 max | 70% coverage to $250 max | 70% coverage to $250 max | 70% coverage to $250 max | 70% coverage to $250 max | 90% coverage to $250 max |
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| Devin Magby-Marks | 336.63 fam 1123.9 | 378.28 fam 1262.96 | 389.51 fam 1300.46 | 398.17 fam 1329.38 | 403.18 fam 1346.09 | 405.53 fam 1353.93 | 405.6 fam 1354.18 | 406.71 fam 1357.88 | 411.6 fam 1374.21 | 412.12 fam 1375.93 | 414.18 fam 1382.81 | 414.5 fam 1383.89 | 414.73 fam 1384.66 | 416.25 fam 1389.72 | 416.56 fam 1390.77 | 423.07 fam 1412.5 | 423.35 fam 1413.43 | 423.94 fam 1415.42 | 425.45 fam 1420.46 | 481.37 fam 1607.16 | 492.05 fam 1642.8 | 497.09 fam 1659.64 | 503.01 fam 1679.41 | 508.13 fam 1696.49 | 511.63 fam 1708.18 | 522.99 fam 1746.1 | 529.94 fam 1769.3 |
| Mark Jordan | 701.84 | 788.67 | 812.09 | 830.15 | 840.58 | 845.48 | 845.64 | 847.95 | 858.15 | 859.22 | 863.51 | 864.19 | 864.68 | 867.83 | 868.48 | 882.06 | 882.64 | 883.88 | 887.03 | 1003.61 | 1025.87 | 1036.39 | 1048.73 | 1059.39 | 1066.69 | 1090.37 | 1104.86 |
| Nicole Baker | 434.4 fam 735.23 | 488.14 fam 826.19 | 502.64 fam 850.73 | 513.82 fam 869.65 | 520.27 fam 880.57 | 523.31 fam 885.71 | 523.41 fam 885.88 | 524.84 fam 888.3 | 531.15 fam 898.98 | 531.81 fam 900.1 | 534.47 fam 904.6 | 534.89 fam 905.31 | 535.19 fam 905.82 | 537.14 fam 909.12 | 537.54 fam 909.8 | 545.95 fam 924.03 | 546.31 fam 924.64 | 547.07 fam 925.93 | 549.02 fam 929.23 | 621.18 fam 1051.36 | 634.96 fam 1074.68 | 641.47 fam 1085.7 | 649.11 fam 1098.63 | 655.71 fam 1109.8 | 660.23 fam 1117.45 | 674.88 fam 1142.25 | 683.85 fam 1157.43 |
| Ray R Diaz | 355.88 | 399.91 | 411.79 | 420.95 | 426.23 | 428.72 | 428.8 | 429.97 | 435.14 | 435.69 | 437.86 | 438.21 | 438.46 | 440.05 | 440.38 | 447.27 | 447.56 | 448.19 | 449.79 | 508.9 | 520.19 | 525.52 | 531.78 | 537.19 | 540.89 | 552.9 | 560.25 |
| Robert Bohn | 701.84 | 788.67 | 812.09 | 830.15 | 840.58 | 845.48 | 845.64 | 847.95 | 858.15 | 859.22 | 863.51 | 864.19 | 864.68 | 867.83 | 868.48 | 882.06 | 882.64 | 883.88 | 887.03 | 1003.61 | 1025.87 | 1036.39 | 1048.73 | 1059.39 | 1066.69 | 1090.37 | 1104.86 |
| Total | 2530.59 w deps 3618.69 | 2843.67 w deps 4066.40 | 2928.12 w deps 4187.16 | 2993.24 w deps 4280.28 | 3030.84 w deps 4334.05 | 3048.52 w deps 4359.32 | 3049.09 w deps 4360.14 | 3057.42 w deps 4372.05 | 3094.19 w deps 4424.63 | 3098.06 w deps 4430.16 | 3113.53 w deps 4452.29 | 3115.98 w deps 4455.79 | 3117.74 w deps 4458.30 | 3129.10 w deps 4474.55 | 3131.44 w deps 4477.91 | 3180.41 w deps 4547.92 | 3182.50 w deps 4550.91 | 3186.96 w deps 4557.30 | 3198.32 w deps 4573.54 | 3618.67 w deps 5174.64 | 3698.94 w deps 5289.41 | 3736.86 w deps 5343.64 | 3781.36 w deps 5407.28 | 3819.81 w deps 5462.26 | 3846.13 w deps 5499.90 | 3931.51 w deps 5621.99 | 3983.76 w deps 5696.70 |