|  |
| Plan | Gold 80 HMO 500/30 |
| Metal | Gold |
| Network | Kaiser Permanente |
| Deductible | $500 ($1000 family) |
| Coinsurance | Fixed copays for most services |
| Out of Pocket Mzx | $7000/14,000 family |
| Ambulance | $250 copayment |
| Chiropractor | Chiro & acupuncture - $15 copay/20 visits max |
| Durable Med Equip | 80% coverage |
| Emergency Room | $250 copay |
| Hospital | $600 per day per admit ($3000 max) |
| Infertility | Optional |
| Lab & X-Ray | $20 lab/$40 X-ray |
| Office Visit | $30 copayment |
| Specialist | $35 copayment |
| Outpatient Surgery | $600 copayment (per procedure) |
| Physical Therapy | $30 copayment |
| Inpatient Psych | $600 per day per admit ($3000 max) |
| Outpatient Psych | $30 copayment |
| Rx Tier 1 | $15 copayment |
| Rx Tier 2 | $50 copayment |
| Rx Tier 3 | $50 copayment |
| Rx Tier 4 | 80% coverage (ded waived) |
| Links | Brochure Formulary Providers |
| Arpit B | 696.27 |
| Manohar Lal | 921.7 |
| Total | 1617.97 |