Prepared for Faubel ConstructionZip code 94941Eff date 12/2024

Plan	Silver PPO 55/2500/45%	Silver PPO 2250/60	Silver PPO 2500/55	Silver PPO 50/2200/40%	Silver PPO 45/1750/40%	Silver Full PPO Savings 2600/35% OffEx	Silver Full PPO Savings 2300/30% OffEx	Silver 70 PPO 2500/55 (shop)
Metal	Silver	Silver	Silver	Silver	Silver	Silver	Silver	Silver
Network	Prudent Buyer PPO	Full PPO	Full PPO	Prudent Buyer PPO	Prudent Buyer PPO	Full PPO Network	Full PPO Network	Full PPO Network
Deductible	$2500/$5000 family	$2250/$4500 family	$2500/$5000 family	$2200/$4400 family	$1750/$3500 family	$2600 or $3200/$5200 family	$2300 or $3200/$4600 family	$2500/$5000 family
Coinsurance	55% coverage for most services	60% coverage for most services	65% coverage for most services	60% coverage for most services	60% coverage for most services	65% coverage for most services	70% coverage for most services	65% coverage for most services
Out of Pocket Mzx	$8700/$17,400 family	$9100/$18,200 family	$8600/$17,200 family	$8600/$17,200 family	$9100/$18,200 family	$7900//$15,800 family	$7900//$15,800 family	$8600/$17,200 family
Ambulance	55% coverage (ded applies)	60% coverage (ded applies)	65% coverage (ded applies)	60% coverage (ded applies)	60% coverage (ded applies)	65% coverage after ded	70% coverage after ded	65% coverage (after deductible)
Chiropractor	50% cov (20 visits max)	Optional	Optional	50% cov (20 visits max)	50% cov (20 visits max)	65% coverage after ded(20 visits max)	70% coverage after ded (20 visits max)	Not covered
Durable Med Equip	50% coverage (ded applies)	60% coverage (ded applies)	65% coverage (ded waived)	50% coverage (ded applies)	50% coverage (ded applies)	50% coverage (after deductible)	50% coverage after ded	65% coverage (after deductible)
Emergency Room	$100 copay then 55% coverage (ded apples)	60% coverage (ded applies)	65% coverage (ded applies)	$350 copay then 60% cov (ded applies)	$300 copay then 60% cov (ded applies)	$150 copay then 65% cov after ded	70% coverage after ded	65% coverage (after deductible)
Hospital	55% coverage (ded applies)	60% coverage (ded applies)	65% coverage (ded applies)	60% coverage (ded applies)	60% coverage (ded applies)	65% coverage after ded	70% coverage after ded	65% coverage (after deductible)
Infertility	Optional	Optional	Optional	Optional	Optional	Optional	Optional	Not covered
Lab & X-Ray	$20 lab/X-ray $20	Lab: $40 copay (ded waived)/X-ray $65 copay (ded waived)	Lab: $55 copay (ded waived)/X-ray $90 copay (ded waived)	$20 lab/X-ray $20	$20 lab/X-ray $20	65% coverage after ded	70% coverage after ded	$55 lab/$90 X-ray
Office Visit	$55 copayment	$60 copayment	$55 copayment	$50 copayment	$45 copayment	65% coverage after ded	70% coverage after ded	$55 copayment
Specialist	$90 copayment	$85 copayment	$90 copayment	$90 copayment	$95 copayment	65% coverage after ded	70% coverage after ded	$90 copayment
Outpatient Surgery	$250 copay then 55% coverage (ded applies)	60% coverage (ded applies)	65% coverage (ded applies)	60% cov after $200 copay (ded applies)	$250 copay then 60% coverage	$150 copayment (then 65% coverage) after ded	70% coverage after ded	65% coverage (after deductible)
Physical Therapy	$55 copayment	$60 copayment	$55 copayment	$50 copayment	$45 copayment	65% coverage after ded	70% coverage after ded	$55 copayment (after deductible)
Inpatient Psych	55% coverage (ded applies)	60% coverage (ded applies)	65% coverage (ded applies)	60% coverage (ded applies)	60% coverage (ded applies)	65% coverage after ded	70% coverage after ded	$55 copayment
Outpatient Psych	$55 copayment	$60 copayment	$55 copayment	$50 copayment	$45 copayment	65% coverage after ded	70% coverage after ded	60% coverage (after deductible)
Rx Tier 1	$15 copayment	$20 copayment	$20 copayment	$15 copayment	$15 copayment	65% cov up to $250 per Rx after ded	$25 copayment after ded	$20 copayment
Rx Tier 2	$70 copayment (after $200 Rx ded)	$65 copayment after $350 Rx ded	60% cov to $500 after $500 Rx ded	$70 copay after $300 Rx ded	$70 copay after $300 Rx ded	65% cov up to $250 per Rx after ded	$75 copayment after ded	$75 copayment (after $300 Rx ded)
Rx Tier 3	$110 copay after $200 Rx ded	$85 copayment ($350 Rx ded applies)	$105 copayment ($300 Rx ded applies)	$110 copay after $300 Rx ded	$110 copay after $300 Rx ded	65% cov up to $250 per Rx after ded	$100 copay (after ded)	$105 copayment (after $300 Rxded)
Rx Tier 4	70% coverage to $250 max after $200 Rx ded	60% coverage (up to $300 after $350 Rx ded)	70% coverage (up to $250 after $300 Rx ded)	70% coverage to $250 max $300 Rx ded	70% coverage to $250 max after $300 Rx ded	65% cov up to $250 per Rx after ded	70% coverage up to $250 per Rx after ded	70% coverage up to $250 per Rx (after $300 Rxded)
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
Adrian	621.13	624.17	628.04	629.23	633.97	642.94	659.38	742.53
Christopher	752.58	756.27	760.95	762.39	768.14	779.01	798.93	899.67
Daniel1	784.19	788.03	792.91	794.41	800.4	811.73	832.49	937.46
Daniel2	700.9	704.34	708.7	710.04	715.39	725.52	744.07	837.89
Deborah	1441.44	1448.51	1457.47	1460.23	1471.23	1492.06	1530.22	1723.17
Ed	1505.16	1512.54	1521.9	1524.78	1536.27	1558.02	1597.86	1799.34
Jorge	593.53	596.44	600.14	601.27	605.8	614.38	630.09	709.54
Mercedes	1023.51	1028.53	1034.89	1036.85	1044.66	1059.45	1086.54	1223.55
Osman	613.1	616.11	619.92	621.09	625.77	634.63	650.86	732.93
Parsons	1305.98 fam 1736.96	1312.38 fam 1745.47	1320.5 fam 1756.27	1323 fam 1759.6	1332.97 fam 1772.86	1351.84 fam 1797.95	1386.41 fam 1843.93	1561.23 fam 2076.44
Roberto	680.83	684.17	688.41	689.71	694.91	704.74	722.77	813.9
Robin	1222.69	1228.69	1236.29	1238.63	1247.96	1265.63	1297.99	1461.66
Total	11245.04 w deps 11676.02	11300.18 w deps 11733.27	11370.12 w deps 11805.89	11391.63 w deps 11828.23	11477.47 w deps 11917.36	11639.95 w deps 12086.06	11937.61 w deps 12395.13	13442.87 w deps 13958.08