|  |
| Plan | Platinum 90 PPO 0/15 + Child Dental |
| Metal | Platinum |
| Network | Full PPO |
| Deductible | None |
| Coinsurance | 90% coverage for most services |
| Out of Pocket Mzx | $4500/$9000 family |
| Ambulance | $150 copaymet |
| Chiropractor | Optional |
| Durable Med Equip | 90% coverage |
| Emergency Room | $150 copayment |
| Hospital | 90% coverage |
| Infertility | Optional |
| Lab & X-Ray | Lab: $15 copay/X-ray $30 copay |
| Office Visit | $15 copayment |
| Specialist | $30 copayment |
| Outpatient Surgery | 90% coverage |
| Physical Therapy | $15 copayment |
| Inpatient Psych | 90% coverage |
| Outpatient Psych | $15 copayment |
| Rx Tier 1 | $5 copayment |
| Rx Tier 2 | $15 copayment |
| Rx Tier 3 | $25 copayment |
| Rx Tier 4 | 90% coverage (up to $250 per 30 day script) |
| Links | Brochure Formulary Providers |
| Jack | 800.65 fam 1423.63 |
| Manny | 895.79 fam 3127.52 |
| Moe | 700.35 |
| Total | 2396.79 w deps 5251.50 |