|  | | |
| Plan | Harmony HMO BR-TI 30%/2250 ded | Value Alliance HMO BR-TW 40%/7200 ded | Harmony HMO BR-TH 55-80/40%/2250 ded |
| Metal | Silver | Bronze | Silver |
| Network | Harmony HMO | Value Alliance HMO | Harmony HMO |
| Deductible | $2250/$4500 family | $7200/$14,400 family | $2250/$4500 family |
| Coinsurance | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% coverage for most services |
| Out of Pocket Mzx | $8150 ($16,300 family) | $8150 ($16,300 family) | $8150 ($16,300 family) |
| Ambulance | 70% coverage (after deductible) | 60% coverage (after deductible) | $100 copayment |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 70% coverage (after deductible) | 60% coverage (after deductible) | $50 copayment |
| Emergency Room | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% coverage (after deductible) |
| Hospital | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% coverage (after deductible) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 70% coverage (after deductible) | 60% coverage (after deductible) | $80 lab/$45 X-ray |
| Office Visit | 70% coverage (after deductible) | 60% coverage (after deductible) | $55 copayment |
| Specialist | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% cov (ded applies) |
| Outpatient Surgery | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% cov (ded applies) |
| Physical Therapy | 70% coverage (after deductible) | 60% coverage (after deductible) | $30 copayment (after ded) |
| Inpatient Psych | 70% coverage (after deductible) | 60% coverage (after deductible) | 60% coverage (after deductible) |
| Outpatient Psych | 70% coverage (after deductible) | 60% coverage (after deductible) | $55 copayment |
| Rx Tier 1 | $20 copayment | 60% coverage after med ded (max $500) | $15 copayment |
| Rx Tier 2 | $50 copayment after $300 Rx ded | 60% coverage after med ded (max $500) | $40 copayment after $$300 Rx ded |
| Rx Tier 3 | $100 copayment after $300 Rx ded | 60% coverage after med ded (max $500) | $80 copayment after $300 Rx ded |
| Rx Tier 4 | 75% coverage after $300 rx ded (max $250) | 60% coverage after med ded (max $500) | 75% coverage after $300 rx ded (max $250) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Jane Doe | 250.73 | 256.25 | 276.98 |
| Joe Blow | 320.7 fam 1119.67 | 327.76 fam 1144.33 | 354.27 fam 1236.89 |
| Total | 571.43 w deps 1370.40 | 584.01 w deps 1400.58 | 631.25 w deps 1513.87 |