|  | |
| Plan | Bronze Trio HMO 7000/70 Offex | Bronze Tandem PPO 7500/65 OffEx |
| Metal | Bronze | Bronze |
| Network | Trio ACO Network | Tandem PPO Network |
| Deductible | $7000/$14,000 family | $7500/$15,000 family |
| Coinsurance | Fixed copays for most services | 50% coverage for most services |
| Out of Pocket Mzx | $8350/$16,700 family | $8350/$16,700 family |
| Ambulance | 50% coverage (after deductible | 50% coverage (after deductible) |
| Chiropractor | $15 copayment (20 visits max) | 50% coverage (after deductible) |
| Durable Med Equip | 50% coverage (after deductible) | 50% coverage (after deductible) |
| Emergency Room | 50% coverage (after deductible) | 50% coverage (after deductible) |
| Hospital | 50% coverage (after deductible) | 50% coverage (after deductible) |
| Infertility | Optional | Optional |
| Lab & X-Ray | Lab: $65 copay/X-ray: $115 | 50% coverage (after deductible) |
| Office Visit | $70 copayment | $65 copay (after deductible) |
| Specialist | $80 copayment | 50% coverage (after deductible) |
| Outpatient Surgery | $150 per surgery | 50% coverage (after deductible) |
| Physical Therapy | $70 copayment | 50% coverage (after deductible) |
| Inpatient Psych | 50% coverage (after deductible) | 50% coverage (after deductible) |
| Outpatient Psych | $70 copayment | $65 copay (after deductible) |
| Rx Tier 1 | $25 copayment | $20 copay |
| Rx Tier 2 | $115 copayment (after medical ded) | 50% coverage up to $250 per Rx after med ded |
| Rx Tier 3 | $160 copayment (after medical ded) | 50% coverage up to $250 per Rx after med ded |
| Rx Tier 4 | 50% cov to $500 after medical ded | 50% coverage up to $500 per Rx after med ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Juan | 275.19 fam 619.75 | 345.78 fam 778.71 |
| Maritza | 252 | 316.63 |
| Mitzy | 439.59 | 552.34 |
| Total | 966.78 w deps 1311.34 | 1214.75 w deps 1647.68 |