|  | |
| Plan | Gold 80 HRA HMO 2250 | Gold 80 HMO 250/35 |
| Metal | Gold | Gold |
| Network | Kaiser Permanente | Kaiser Permanente |
| Deductible | $2250/$4500 family | $250 ($500 family) |
| Coinsurance | 75% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7800/15,600 family | $7800/15,600 family |
| Ambulance | 75% coverage (after deductible) | $250 copayment (after ded) |
| Chiropractor | Not covered | Not covered |
| Durable Med Equip | 50% coverage (ded applies) | 80% coverage (after ded) |
| Emergency Room | 75% coverage (ded applies) | $250 copayment (after ded) |
| Hospital | 75% coverage (ded applies) | $600 per day 1st 5 days |
| Infertility | Optional | Optional |
| Lab & X-Ray | 75% coverage (ded applies) | $35 lab/$55 X-ray |
| Office Visit | $35 copayment | $35 copayment |
| Specialist | $50 copayment | $55 copayment |
| Outpatient Surgery | 75% coverage (ded applies) | $335 copayment |
| Physical Therapy | $35 copayment (ded applies) | $35 copayment |
| Inpatient Psych | 75% coverage (ded applies) | $600 per day 1st 5 days |
| Outpatient Psych | $35 copayment | $35 copayment |
| Rx Tier 1 | $15 copayment | $15 copayment |
| Rx Tier 2 | $30 copayment (aftr $100 Rx ded) | $40 copayment |
| Rx Tier 3 | $30 copayment (aftr $100 Rx ded) | $40 copayment |
| Rx Tier 4 | 80% cov up to $250 per Rx after $100 Rx ded | 80% coverage to $250 |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| EE | 441.26 | 503.21 |
| Randy | 609.86 fam 1130.94 | 695.48 fam 1289.72 |
| Total | 1051.12 w deps 1572.20 | 1198.69 w deps 1792.93 |