|  |
| Plan | Silver Select PPO 50/2250/20% 4HZP |
| Metal | Silver |
| Network | Select PPO |
| Deductible | $2520/$4500 family |
| Coinsurance | 80% coverage for most services |
| Out of Pocket Mzx | $7800/$15,600 family |
| Ambulance | $250 copay |
| Chiropractor | Not covered |
| Durable Med Equip | 80% coverage (ded waived) |
| Emergency Room | $400 copay |
| Hospital | 80% coverage (ded applies) |
| Infertility | Not covered |
| Lab & X-Ray | $40 lab/$85 X-ray copayment |
| Office Visit | $50 copayment |
| Specialist | $85 copayment |
| Outpatient Surgery | 80% coverage (ded applies) |
| Physical Therapy | $50 copayment |
| Inpatient Psych | 80% coverage (ded applies) |
| Outpatient Psych | $50 copayment |
| Rx Tier 1 | $17 copay after $300 Rx ded |
| Rx Tier 2 | $65 copayment after $300 Rx ded |
| Rx Tier 3 | $90 copayment after $300 Rx ded |
| Rx Tier 4 | 80% coverage to $250 max $300 Rx ded |
| Links | Brochure Formulary Providers |
| Michelle Awaa | 756.46 fam 2008.18 |
| Total | 756.46 w deps 2008.18 |