|  | | | | |
| Plan | Silver 70 HMO 1900/65 (shop) | Gold 80 HMO 1000/40 | Gold 80 HMO 250/35 | Gold 80 HMO 0/30 (shop) | Platinum 90 HMO 0/20 (shop) |
| Metal | Silver | Gold | Gold | Gold | Platinum |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $1900/$3800 family | $1000 ($2000 family) | $250 ($500 family) | None | None |
| Coinsurance | 55% coverage for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8750/17,500 family | $7800/15,600 family | $7800/15,600 family | $7500/15,000 family | $4500/$9000 family |
| Ambulance | 55% coverage (after ded) | $350 copayment (after ded) | $250 copayment (after ded) | $250 copayment (after ded) | $150 copayment |
| Chiropractor | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | Not covered | $15 copay (20 visits ann max) | Not covered |
| Durable Med Equip | 55% coverage (after ded) | 80% coverage | 80% coverage (after ded) | 80% coverage (after ded) | 90% coverage |
| Emergency Room | 55% coverage (after ded) | $350 copayment (after ded) | $250 copayment (after ded) | $250 copayment (after ded) | $150 copay |
| Hospital | 55% coverage (after ded) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $250 per day 1st 5 days |
| Infertility | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | $30 lab/$75 X-ray after ded | $30 lab/$60 X-ray | $35 lab/$55 X-ray | $30 lab/$40 X-ray | $20 lab/$30 X-ray |
| Office Visit | $65 copayment | $40 copayment | $35 copayment | $30 copayment | $20 copayment |
| Specialist | $100 copayment | $60 copayment | $55 copayment | $50 copayment | $30 copayment |
| Outpatient Surgery | 55% coverage (after ded) | $350 copayment (ded applies) | $335 copayment | $320 copayment | $125 copayment (per procedure) |
| Physical Therapy | $65 copayment | $40 copayment | $35 copayment | $30 copayment | $20 copayment |
| Inpatient Psych | 55% coverage (after ded) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $250 per day 1st 5 days |
| Outpatient Psych | $65 copayment | $40 copayment | $35 copayment | $30 copayment | $20 copayment |
| Rx Tier 1 | $20 copay | $20 copayment | $15 copayment | $15 copayment | $5 copayment |
| Rx Tier 2 | $100 copayment | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment | $20 copayment |
| Rx Tier 3 | $100 copayment | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment | $20 copayment |
| Rx Tier 4 | 80% cov $250 max ben (after medical ded) | 80% coverage to $250 (after $250 Rx ded) | 80% coverage to $250 | 80% coverage to $250 max | 90% cov up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| EE | 421.74 | 473.19 | 503.21 | 529.5 | 559.37 |
| Randy | 582.88 | 653.98 | 695.48 | 731.81 | 773.09 |
| Total | 1004.62 | 1127.17 | 1198.69 | 1261.31 | 1332.46 |