Zip: 92804	Apply	Apply	Apply	Apply	Apply	Apply
Monthly Total	1828.76	1935.98	2036.62	2227.87	2256.02	2316.13
Plan Name	Bronze 60 PPO	Gold 80 Trio HMO	Bronze 60 PPO	Gold 80 HMO	Platinum 90 Trio HMO	Silver 1750 PPO
Deductible	5800 ($11,600 per family)	None	5800 ($11,600 per family)	None	None	$1750 ($3500 per family)
Coinsurance	60% coverage for most services	80% coverage for most services	60% coverage for most services	80% coverage for most services	90% coverage most services	65% coverage for most services
Out of Pocket Max	$9800 (19,600 family)	$9200 (18,400 family)	$9800 (19,600 family)	$9200 (18,400 family)	$5000 (10,000 family)	$9250 (18,500 family)
Ambulance	60% coverage (ded applies)	$250 copayment	60% coverage (ded applies)	$250 copayment	$150 copayment	65% coverage (ded applies)
Chiropractic	Not covered	Not covered	Not covered	Not covered	Not covered	$15 copay (15 visits per year)
Durable Medical Equipt	60% coverage (ded applies)	80% coverage	60% coverage (ded applies)	80% coverage	90% coverage	65% coverage
Emergency Room	60% coverage (ded applies)	$350 copay	60% coverage (ded applies)	$350 copay	$175 copay	65% coverage (ded applies)
Hospital Stay	60% coverage (ded applies)	70% coverage	60% coverage (ded applies)	70% coverage	90% coverage	65% coverage (ded applies)
Lab & X-ray	$50 lab copay/60% x-ray after ded	$40 lab/$75 x-ray	$50 lab copay/60% x-ray after ded	$40 lab/$75 x-ray	$15 lab/$30x-ray	Lab $50 copay / X-Ray 65% cov after ded
Office Visit	$60 copayment	$40 copayment	$60 copayment	$40 copayment	$15 copayment	$55 copayment
Specialist	$95 copay (ded applies)	$70 copayment	$95 copay (ded applies)	$70 copayment	$30 copayment	$85 copayment
Physical Therapy	$60 copayment	$40 copayment	$60 copayment	$40 copayment	$15 copayment	65% coverage (ded applies)
Outpatient Surgery	60% coverage (ded applies)	70% coverage	60% coverage (ded applies)	70% coverage	90% coverage	65% or 75% coverage/after deductible
Psych (Inpatient)	60% coverage after ded	70% coverage	60% coverage after ded	70% coverage	90% coverage	65% coverage (ded applies)
Psych (Outpatient)	$60 copayment	$40 copayment	$60 copayment	$40 copayment	$15 copayment	$55 copayment
Rx Tier 1	$20 copay	$19 copayment	$20 copay	$19 copayment	$9 copayment	$20 copay after $300 Rx deductible
Rx Tier 2	60% coverage up to $500 per Rx after $450 Rx ded	$60 copayment	60% coverage up to $500 per Rx after $450 Rx ded	$60 copayment	$16 copayment	$75 copayment (after $300 Rx ded)
Rx Tier 3	60% coverage up to $500 per Rx after $450 Rx ded	$90 copayment	60% coverage up to $500 per Rx after $450 Rx ded	$90 copayment	$25 copayment	$90 copayment (after $300 Rx ded)
Rx Tier 4	60% coverage up to $500 per Rx after $450 Rx ded	80% coverage up to $250 per Rx	60% coverage up to $500 per Rx after $450 Rx ded	80% coverage up to $250 per Rx	90% coverage up to $250 per Rx	65% coverage up to $250 per Rx (after $300 Rx ded)
Links	Brochure Providers Formulary	Brochure Providers Formulary	Brochure Providers Formulary	Brochure Providers Formulary	Brochure Providers Formulary	Brochure Providers Formulary
Subscriber (55)	955.06	1011.06	1063.62	1163.50	1178.20	1209.60
Spouse (53)	873.69	924.92	973.00	1064.37	1077.81	1106.54
Annual Premium Tota	$ 21,945	$ 23,232	$ 24,439	$ 26,734	$ 27,072	$ 27,794
Annual Max Exposure	$ 31,745Family: $ 41,545	$ 32,432Family: $ 41,632	$ 34,239Family: $ 44,039	$ 35,934Family: $ 45,134	$ 32,072Family: $ 37,072	$ 37,044Family: $ 46,294