|  | |
| Plan | SmartCare HMO Silver $55 | SmartCare HMO Gold $55 |
| Metal | Silver | Gold |
| Network | SmartCare HMO | SmartCare HMO |
| Deductible | None | None |
| Coinsurance | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8500/$17,000 family | $8500/$17,000 family |
| Ambulance | $350 copayment | $350 copayment |
| Chiropractor | Optional | Optional |
| Durable Med Equip | 60% coverage | 60% coverage |
| Emergency Room | $350 copayment | $350 copayment |
| Hospital | $900 per day (1st 5 days) | $900 per day (1st 5 days) |
| Infertility | Optional | Optional |
| Lab & X-Ray | Lab: $40 copay/X-ray $60 copay | Lab: $40 copay/X-ray $60 copay |
| Office Visit | $55 copayment | $55 copayment |
| Specialist | $75 copayment | $75 copayment |
| Outpatient Surgery | $520 or $1300 copay | $520 or $1300 copay |
| Physical Therapy | $55 copayment | $55 copayment |
| Inpatient Psych | $900 per day (1st 5 days) | $900 per day (1st 5 days) |
| Outpatient Psych | $55 copayment | $55 copayment |
| Rx Tier 1 | $15 copayment | $15 copayment |
| Rx Tier 2 | $50 copay (after $450 Rx ded) | $50 copay (after $450 Rx ded) |
| Rx Tier 3 | $70 copay (after $450 Rx ded) | $70 copay (after $450 Rx ded) |
| Rx Tier 4 | 50% (after $750 Rx ded) | 60% cov up to $250 per Rx after $450 Rx deductible |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Anthony Vargas | 500.06 | 552.95 |
| MICHAEL DODSON | 458.15 | 506.6 |
| RYAN McADAMS | 381.64 | 422 |
| RYAN ODEGAARD | 365.23 fam 1176.58 | 403.85 fam 1301.01 |
| TRAVIS SHELDON | 597.96 fam 1125.58 | 661.2 fam 1244.62 |
| Total | 2303.04 w deps 3642.01 | 2546.60 w deps 4027.18 |