|  |  | | |
| Plan | Gold Trio HMO 1000/35 OffEx | SmartCare HMO Gold $50 | Salud HMO Gold $50 | SmartCare HMO Gold $40 |
| Metal | Gold | Gold | Gold | Gold |
| Network | Trio ACO Network | SmartCare HMO | Salud HMO | SmartCare HMO |
| Deductible | $1000/$2000 family | None | None | None |
| Coinsurance | 80% coverage for most services | 60% coverage for most services | 60% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $2000/$4000 family | $7000,$14,000 family | $7000,$14,000 family | $6500/$13,000 family |
| Ambulance | $175 copayment | $300 copayment | $300 copayment | $300 copayment |
| Chiropractor | $15 copayment (15 visits max) | Optional | Optional | Optional |
| Durable Med Equip | 50% coverage (after deductible) | 60% coverage | 60% coverage | 60% coverage |
| Emergency Room | $300 copayment (ded applies) | $300 copayment | $300 copayment | $300 copayment |
| Hospital | 80% coverage (after deductible) | $750 per day (1st 4 days) | $750 per day (1st 4 days) | $750 per day (1st 3 days) |
| Infertility | Not covered | Optional | Optional | Optional |
| Lab & X-Ray | $40 lab/$60 X-ray | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $50 copay | Lab: $40 copay/X-ray $40 copay |
| Office Visit | $35 copayment | $50 copayment | $50 copayment | $40 copayment |
| Specialist | $60 copayment | $70 copayment | $70 copayment | $60 copayment |
| Outpatient Surgery | $150 or $300 per surgery (after deductible) | $1200 copayment | $1200 copayment | $1100 copayment |
| Physical Therapy | $35 copayment | $50 copayment | $50 copayment | $40 copayment |
| Inpatient Psych | 80% coverage (after deductible) | $750 per day (1st 4 days) | $750 per day (1st 4 days) | $750 per day (1st 3 days) |
| Outpatient Psych | $35 copayment | $50 copayment | $50 copayment | $40 copayment |
| Rx Tier 1 | $15 copayment (after $100 Rx ded) | $15 copayment | $15 copayment | $5 copayment |
| Rx Tier 2 | $35 copayment (after $100 Rx ded) | $50 copay (after ded) | $50 copay (after ded) | $30 copayment |
| Rx Tier 3 | $55 copayment(after $100 Rx ded) | $70 copay (after ded) | $70 copay (after ded) | $50 copayment |
| Rx Tier 4 | 80% coverage up to $250 per Rx after $100 Rx ded | 60% cov up to $250 per 30 day script after Rx deductible | 60% cov up to $250 per 30 day script after Rx deductible | 70% cov ($250 max per 30 day script) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Jack | 859.08 | 861.3 | 861.3 | 874.71 |
| Jane Doe | 349.93 | 350.84 | 350.84 | 356.3 |
| Joe Blow | 343.06 fam 1131.12 | 343.95 fam 1134.05 | 343.95 fam 1134.05 | 349.3 fam 1151.7 |
| Manny | 611.38 fam 1170.35 | 612.96 fam 1173.38 | 612.96 fam 1173.38 | 622.5 fam 1191.64 |
| Moe | 822.71 | 824.84 | 824.84 | 837.68 |
| Total | 2986.16 w deps 4333.19 | 2993.89 w deps 4344.41 | 2993.89 w deps 4344.41 | 3040.49 w deps 4412.03 |