|  | | |
| Plan | Silver 70 PPO 2250/50 w Child Dental (shop) | Gold Full PPO 0/25 OffEx | Platinum Full PPO 250/15 OffEx |
| Metal | Silver | Gold | Platinum |
| Network | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $2250/$4500 family | None | $250/$500 family |
| Coinsurance | 70% coverage for most services | Fixed copays for most services | 90% coverage for most services |
| Out of Pocket Mzx | $8200/$16,400 family | $8150/$16,300 family | $3000/6000 family |
| Ambulance | 70% coverage (after deductible) | $150 copayment | 90% coverage (after deductible) |
| Chiropractor | Not covered | $10 per visit (20 visits max) | $10 per visit (20 visits max) |
| Durable Med Equip | 70% coverage (after deductible) | 50% coverage | 50% coverage (after deductible) |
| Emergency Room | 70% coverage (after deductible) | $250 copay plus 20% | $150 copayment then 90% cov (after ded) |
| Hospital | 70% coverage (after deductible) | 80% coverage (after deductible | 90% coverage (after deductible) |
| Infertility | Not covered | Optional | Optional |
| Lab & X-Ray | $50 lab/$85 X-ray | Lab $30 copay / X-ray $50 copay | Lab $10 copay / X-ray $30 copay |
| Office Visit | $50 copayment | $30 copayment | $10 copayment |
| Specialist | $85 copayment | $55 copayment | $10 copayment |
| Outpatient Surgery | 70% coverage (after deductible) | 80% coverage | 90% coverage (after deductible) |
| Physical Therapy | $50 copayment (after deductible) | 80% coverage | 90% coverage (after deductible) |
| Inpatient Psych | 70% coverage (after deductible) | 80% coverage (after deductible | 90% coverage (after deductible) |
| Outpatient Psych | $50 copayment | $30 copayment | $10 copayment |
| Rx Tier 1 | $17 copayment | $15 copayment | $10 copayment |
| Rx Tier 2 | $70 copayment (after $300 Rx ded) | $50 copayment | $25 copayment |
| Rx Tier 3 | $100 copayment (after $300 Rxded) | $80 copayment | $40 copayment |
| Rx Tier 4 | 70% coverage up to $250 per Rx (after $300 Rxded) | 70% coverage up to $250 per Rx | 80% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Anita Lal | 914.87 fam 1290.28 | 998.76 fam 1408.59 | 1122.12 fam 1582.57 |
| Bhatia, Jenny | 435.1 | 474.99 | 533.66 |
| Lal, Annie | 420.08 | 458.6 | 515.24 |
| Total | 1770.05 w deps 2145.46 | 1932.35 w deps 2342.18 | 2171.02 w deps 2631.47 |