|  | |
| Plan | Gold Full PPO 750/30 OffEx | Gold Full PPO 0/25 OffEx |
| Metal | Gold | Gold |
| Network | Full PPO Network | Full PPO Network |
| Deductible | $750/$1500 family | None |
| Coinsurance | 80% coverage for most services | 70% coverage for most services |
| Out of Pocket Mzx | $8150/$16,100 family | $8150/$16,100 family |
| Ambulance | 80% coverage | 70% coverage |
| Chiropractor | $10 per visit (20 visits max) | $10 per visit after ded (20 visits max) |
| Durable Med Equip | 50% coverage | 50% coverage |
| Emergency Room | $250 copay after ded then 20% | $250 copay then 70% coverage |
| Hospital | 80% coverage after ded | 70% coverage |
| Infertility | Optional | Optional |
| Lab & X-Ray | $30 lab/$50 X-ray | $25 lab/$50 X-ray |
| Office Visit | $30 copayment | $25 copayment |
| Specialist | $55 copayment | $50 copayment |
| Outpatient Surgery | $150 copayment then 80% coverage after ded | $150 copayment (then 70% coverage) |
| Physical Therapy | 80% coverage after ded | 70% coverage |
| Inpatient Psych | 80% coverage after ded | 70% coverage |
| Outpatient Psych | $30 copayment | $25 copayment |
| Rx Tier 1 | $10 copayment | $15 copayment |
| Rx Tier 2 | $40 copayment (after $250 Rx ded) | $40 copayment |
| Rx Tier 3 | $70 copayment | $60 copayment |
| Rx Tier 4 | 70% cov after $100 Rx ded up to $250 per Rx | 70% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| ganesh | 1126.31 fam 2098.47 | 1153.73 fam 2149.56 |
| neeraj | 381.54 | 390.83 |
| Total | 1507.85 w deps 2480.01 | 1544.56 w deps 2540.39 |