|  | | | |
| Plan | Gold 80 HMO 1000/40 | Gold 80 HMO 250/35 | Gold 80 HMO 0/30 (shop) | Platinum 90 HMO 0/10 (shop) |
| Metal | Gold | Gold | Gold | Platinum |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $1000 ($2000 family) | $250 ($500 family) | None | None |
| Coinsurance | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7800/15,600 family | $7800/15,600 family | $7500/15,000 family | $3000/$6000 family |
| Ambulance | $350 copayment (after ded) | $250 copayment (after ded) | $250 copayment (after ded) | $150 copayment |
| Chiropractor | $15 copay (20 visits ann max) | Not covered | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) |
| Durable Med Equip | 80% coverage | 80% coverage (after ded) | 80% coverage (after ded) | 90% coverage |
| Emergency Room | $350 copayment (after ded) | $250 copayment (after ded) | $250 copayment (after ded) | $200 copay |
| Hospital | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $500 per admission |
| Infertility | Optional | Optional | Optional | Optional |
| Lab & X-Ray | $30 lab/$60 X-ray | $35 lab/$55 X-ray | $30 lab/$40 X-ray | $20 lab/$40 X-ray |
| Office Visit | $40 copayment | $35 copayment | $30 copayment | $10 copayment |
| Specialist | $60 copayment | $55 copayment | $50 copayment | $20 copayment |
| Outpatient Surgery | $350 copayment (ded applies) | $335 copayment | $320 copayment | $300 copayment (per procedure) |
| Physical Therapy | $40 copayment | $35 copayment | $30 copayment | $10 copayment |
| Inpatient Psych | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $500 per admission |
| Outpatient Psych | $40 copayment | $35 copayment | $30 copayment | $10 copayment |
| Rx Tier 1 | $20 copayment | $15 copayment | $15 copayment | $5 copayment |
| Rx Tier 2 | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment | $15 copayment |
| Rx Tier 3 | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment | $15 copayment |
| Rx Tier 4 | 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 |
| EE | 473.19 | 503.21 | 529.5 | 569.6 |
| Randy | 653.98 fam 1212.77 | 695.48 fam 1289.72 | 731.81 fam 1357.09 | 787.24 fam 1459.88 |
| Total | 1127.17 w deps 1685.96 | 1198.69 w deps 1792.93 | 1261.31 w deps 1886.59 | 1356.84 w deps 2029.48 |