|  |  |  |
| Plan | WholeCare HMO Gold $30 | Gold HMO 35 | AccessPlus Gold 80 HMO 250/35 w Child Dental (shop) |
| Metal | Gold | Gold | Gold |
| Network | Wholecare HMO | CaliforniaCare HMO | AccessPlus HMO |
| Deductible | None | None | $250/$500 family |
| Coinsurance | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7250/$14,500 family | $6750/$13,500 family | $7800/$15,600 family |
| Ambulance | $325 copayment | $150 copayment | $250 copayment |
| Chiropractor | Optional | $15 copay (30 visits max) | Not covered |
| Durable Med Equip | 70% coverage | 50% coverage (ded applies) | 80% coverage |
| Emergency Room | $325 copayment | $325 copayment | $250 copayment |
| Hospital | $750 per day (1st 4 days) | $750 daily 1st 4 days | $600 per day 1st 5 days |
| Infertility | Optional | Optional | Not covered |
| Lab & X-Ray | $40 copay | $15 lab/$100 or $250 X-ray copayment | $35 lab/$55 X-ray |
| Office Visit | $30 copayment | $35 copayment | $35 copayment |
| Specialist | $50 copayment | $70 copayment | $55 copayment |
| Outpatient Surgery | $360 or $900 copay | $550 copayment | $300 copayment |
| Physical Therapy | $30 copayment | $35 copayment | $35 copayment |
| Inpatient Psych | $750 per day (1st 4 days) | $750 daily 1st 4 days | $35 copayment |
| Outpatient Psych | $30 copayment | $35 copayment | $600 per day 1st 5 days |
| Rx Tier 1 | $20 copayment | $10 copayment | $15 copayment |
| Rx Tier 2 | $50 copayment | $50 copayment | $40 copayment |
| Rx Tier 3 | $70 copayment | $90 copayment (ded applies) | $70 copayment |
| Rx Tier 4 | 70% coverage | 70% coverage to $250 max | 80% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Kay | 1065.52 | 1216.79 | 1384.74 |
| Larry | 1137.57 | 1299.06 | 1478.37 |
| Michael | 469.44 fam 1793.95 | 536.08 fam 2048.62 | 610.07 fam 2331.38 |
| Total | 2672.53 w deps 3997.04 | 3051.93 w deps 4564.47 | 3473.18 w deps 5194.49 |