|  |
| Plan | Silver 70 HMO 1900/65 (shop) |
| Metal | Silver |
| Network | Kaiser Permanente |
| Deductible | $1900/$3800 family |
| Coinsurance | 55% coverage for most services |
| Out of Pocket Mzx | $8750/17,500 family |
| Ambulance | 55% coverage (after ded) |
| Chiropractor | $15 copay (20 visits ann max) |
| Durable Med Equip | 55% coverage (after ded) |
| Emergency Room | 55% coverage (after ded) |
| Hospital | 55% coverage (after ded) |
| Infertility | Optional |
| Lab & X-Ray | $30 lab/$75 X-ray after ded |
| Office Visit | $65 copayment |
| Specialist | $100 copayment |
| Outpatient Surgery | 55% coverage (after ded) |
| Physical Therapy | $65 copayment |
| Inpatient Psych | 55% coverage (after ded) |
| Outpatient Psych | $65 copayment |
| Rx Tier 1 | $20 copay |
| Rx Tier 2 | $100 copayment |
| Rx Tier 3 | $100 copayment |
| Rx Tier 4 | 80% cov $250 max ben (after medical ded) |
| Links | Brochure Formulary Providers |
| New Employee | 480.48 |
| Angel O | 723.83 |
| Eric K | 474.27 |
| Haylie K | 388.11 |
| Jose M | 449.82 |
| Roberto F | 388.11 |
| Scott S | 828.61 |
| Total | 3733.23 |