Prepared for group Health Zip code 92883Eff date 3/2022

Plan	Gold 80 HMO 1000/40	Gold 80 HMO 250/35	Platinum 90 PPO 0/15
Metal	Gold	Gold	Platinum
Network	Kaiser Permanente	Kaiser Permanente	Kaiser PPO
Deductible	$1000 ($2000 family)	$250 ($500 family)	None
Coinsurance	Fixed copays for most services	Fixed copays for most services	90% coverage for most services
Out of Pocket Mzx	$7800/15,600 family	$7800/15,600 family	$4500/$9000 family
Ambulance	$350 copayment (after ded)	$250 copayment (after ded)	$150 copayment
Chiropractor	Not covered	Not covered	Not covered
Durable Med Equip	80% coverage	80% coverage (after ded)	90% coverage
Emergency Room	$350 copayment (after ded)	$250 copayment (after ded)	$200 copay
Hospital	$600 per day 1st 5 days (ded applies)	$600 per day 1st 5 days	90% coverage
Infertility	Optional	Optional	Optional
Lab & X-Ray	$30 lab/$60 X-ray	$35 lab/$55 X-ray	$15 lab/$30 X-ray
Office Visit	$40 copayment	$35 copayment	$15 copayment
Specialist	$60 copayment	$55 copayment	$30 copayment
Outpatient Surgery	$350 copayment (ded applies)	$335 copayment	90% coverage
Physical Therapy	$30 copayment	$35 copayment	$15 copayment
Inpatient Psych	$600 per day 1st 5 days (ded applies)	$600 per day 1st 5 days	90% coverage
Outpatient Psych	$40 copayment	$35 copayment	$15 copayment
Rx Tier 1	$20 copayment	$15 copayment	$10 copayment
Rx Tier 2	$50 copay (after $250 Rx ded)	$40 copayment	$25 copayment
Rx Tier 3	$50 copay (after $250 Rx ded)	$40 copayment	$25 copayment
Rx Tier 4	80% coverage to $250 (after $250 Rx ded)	80% coverage to $250	90% cov up to $250 per Rx
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
	249.84	265.35	556.86
Esha C	307.32	326.4	684.97
Monica C	583.29 fam 1166.58	619.49 fam 1238.98	1300.07 fam 2600.14
Vishal C	326.59	346.86	727.92
Total	1467.04 w deps 2050.33	1558.10 w deps 2177.59	3269.82 w deps 4569.89