|  |  |  |
| Plan | Capital 5800 Bronze 60 HMO | Trio Bronze 60 HMO 7000/70 w Child Dental (shop) | WholeCare HMO Silver $55 |
| Metal | Bronze | Bronze | Silver |
| Network | HMO Network | Trio ACO Network | Wholecare HMO |
| Deductible | $5800/$11,600 family | $7000/$14,000 family | None |
| Coinsurance | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8850/$17,700 family | $8850/$17,700 family | $9200/$18,400 family |
| Ambulance | 60% coverage (after deductible) | 50% coverage (after deductible | 50% coverage |
| Chiropractor | $15 copay after ded (20 visits max) | $15 copayment (20 visits max) | Not Covered |
| Durable Med Equip | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage |
| Emergency Room | 60% cov (after deductible) | 50% coverage (after deductible) | 50% coverage |
| Hospital | 60% coverage (after deductible) | 50% coverage (after deductible) | $750 per day (1st 5 days) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% cov after ded | Lab: $65 copay/X-ray: $115 | Lab: $40 copay/X-ray $60 copay |
| Office Visit | $60 copay (ded applies) | $70 copayment | $55 copayment |
| Specialist | $95 copay (ded applies) | $80 copayment | $90 copayment |
| Outpatient Surgery | 60% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage |
| Physical Therapy | $60 copay | $70 copayment | $55 copayment |
| Inpatient Psych | 60% coverage (after deductible) | $70 copayment | $750 per day (1st 5 days) |
| Outpatient Psych | $60 copay (ded applies) | 50% coverage (after deductible) | $55 copayment |
| Rx Tier 1 | $18 copayment (after $500 Rx ded) | $25 copayment | $20 copayment |
| Rx Tier 2 | 60% cov up to $500 (after $500 Rx ded) | $115 copayment (after medical ded) | 50% cov up to $250 after Rx ded |
| Rx Tier 3 | 70% coverage up to $250 (after ded) | $160 copayment (after medical ded) | 50% cov up to $250 after Rx ded |
| Rx Tier 4 | 60% coverage up to $500 (after ded) | 50% cov to $500 after medical ded | 50% cov up to $250 after Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Jane Doe | 460.17 | 475.11 | 477.61 |
| Joe Blow | 394.62 fam 784.3 | 407.43 fam 809.76 | 409.57 fam 814.01 |
| Total | 854.79 w deps 1244.47 | 882.54 w deps 1284.87 | 887.18 w deps 1291.62 |