|  | |
| Plan | WholeCare HMO Silver $55 | WholeCare HMO Gold $40 |
| Metal | Silver | Gold |
| Network | Wholecare HMO | Wholecare HMO |
| Deductible | None | None |
| Coinsurance | 50% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7950/$15,900 family | $7500/$15,000 family |
| Ambulance | 50% coverage | $325 copayment |
| Chiropractor | Optional | Optional |
| Durable Med Equip | 50% coverage | 60% coverage |
| Emergency Room | 50% coverage | $325 copayment |
| Hospital | 50% coverage | $750 per day (1st 5 days) |
| Infertility | Optional | Optional |
| Lab & X-Ray | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay |
| Office Visit | $50 copayment | $40 copayment |
| Specialist | $70 copayment | $60 copayment |
| Outpatient Surgery | 50% coverage | $480 or $1200 copay |
| Physical Therapy | $50 copayment | $40 copayment |
| Inpatient Psych | 50% coverage | $750 per day (1st 5 days) |
| Outpatient Psych | $50 copayment | $40 copayment |
| Rx Tier 1 | $20 copayment | $15 copayment |
| Rx Tier 2 | 50% (after $750 Rx ded) | $50 copayment |
| Rx Tier 3 | 50% (after $750 Rx ded) | $70 copayment |
| Rx Tier 4 | 50% (after $750 Rx ded) | 70% coverage |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| George Jetson | 410.82 fam 1343.46 | 455.79 fam 1490.51 |
| Jack | 930.15 | 1031.97 |
| Lucielle Ball | 386.32 fam 660.71 | 428.61 fam 733.04 |
| Manny | 578.24 fam 1290.74 | 641.54 fam 1432.02 |
| Moe | 378.88 fam 853.26 | 420.36 fam 946.66 |
| Total | 2684.41 w deps 5078.32 | 2978.27 w deps 5634.20 |