|  |  | | |
| Plan | Gold Full PPO 0/25 OffEx | Gold Select PPO 25/350/20 6BTD | Platinum Full PPO 250/10 OffEx | Platinum PPO 5/250/15 WH 6BLC |
| Metal | Gold | Gold | Platinum | Platinum |
| Network | Full PPO Network | Select PPO | Full PPO Network | Prudent Buyer PPO |
| Deductible | None | $350/$700 family | $250/$500 family | $250/$750 family |
| Coinsurance | Fixed copays for most services | 80% coverage for most services | 90% coverage for most services | 85% coverage for most services |
| Out of Pocket Mzx | $8150/$16,300 family | $7800/$15,600 family | $3000/$6000 family | $4200/$8400 family |
| Ambulance | $150 copayment | 80% coverage (ded applies) | 90% coverage | 85% coverage (ded applies) |
| Chiropractor | $10 per visit (20 visits max) | Not covered | $10 per visit (20 visits max) | 20 visits max (other limitations apply) |
| Durable Med Equip | 50% coverage | 80% coverage (ded applies) | 50% coverage | 50% coverage (ded applies) |
| Emergency Room | $250 copay plus 20% | 80% coverage (ded applies) | $150 copayment | $250 copay then 85% coverage |
| Hospital | 80% coverage (after deductible | 80% coverage (ded applies) | 90% coverage | 85% coverage (ded applies) |
| Infertility | Optional | Optional | Optional | Optional |
| Lab & X-Ray | Lab $30 copay / X-ray $50 copay | $25 lab/$65 X-ray copayment | Lab $10 copay / X-ray $30 copay | $10 lab/X-ray $100 then 85% coverage |
| Office Visit | $30 copayment | $25 copayment | $10 copayment | $5 copayment |
| Specialist | $55 copayment | $50 copayment | $10 copayment | $45 copayment |
| Outpatient Surgery | 80% coverage | 80% coverage (ded applies) | $100 copayment (then 90% coverage) | $200 copay then 85% coverage |
| Physical Therapy | 80% coverage | $25 copayment | 90% coverage | $5 copayment |
| Inpatient Psych | 80% coverage (after deductible | 80% coverage (ded applies) | 90% coverage | 85% coverage (ded applies) |
| Outpatient Psych | $30 copayment | $25 copayment | $10 copayment | $5 copayment |
| Rx Tier 1 | $15 copayment | $15 copayment | $10 copayment | $10 copayment |
| Rx Tier 2 | $50 copayment | $50 copayment | $25 copayment | $35 copayment |
| Rx Tier 3 | $80 copayment | $80 copayment | $40 copayment | $70 copayment |
| Rx Tier 4 | 70% coverage up to $250 per Rx | 80% coverage to $250 max | 80% coverage up to $250 per Rx | 70% coverage to $250 max |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Ravinder Asija | 1177.44 fam 2289.72 | 1232.63 fam 2397.04 | 1376.4 fam 2676.62 | 1398.32 fam 2719.25 |
| Tanmay Asija | 429.5 | 449.63 | 502.08 | 510.07 |
| Total | 1606.94 w deps 2719.22 | 1682.26 w deps 2846.67 | 1878.48 w deps 3178.70 | 1908.39 w deps 3229.32 |