Prepared for SC Coatings CorpZip code 92562Eff date 6/2020

Plan	Bronze 60 HMO 6300/65 (shop)	Salud HMO Gold $50	Gold 80 HMO 500/30 (shop)
Metal	Bronze	Gold	Gold
Network	Kaiser Permanente	Salud HMO	Kaiser Permanente
Deductible	$6300/$12,600 family	None	$500 ($1000 family)
Coinsurance	60% coverage for most services	60% coverage for most services	Fixed copays for most services
Out of Pocket Mzx	$7800/15,600 family	$7000,$14,000 family	$7000/14,000 family
Ambulance	60% coverage (after ded)	$300 copayment	$250 copayment (after ded)
Chiropractor	Not covered	Optional	Not covered
Durable Med Equip	60% coverage (after ded)	60% coverage	80% coverage
Emergency Room	60% coverage (after ded)	$300 copayment	$250 copayment (after ded)
Hospital	60% coverage (after ded)	$750 per day (1st 4 days)	$600 per day per admit ($3000 max)
Infertility	Optional	Optional	Optional
Lab & X-Ray	Lab $40/X-ray 60% coverage (after ded)	Lab: $40 copay/X-ray $50 copay	$20 lab/$40 X-ray
Office Visit	$65 copayment first 3 visits then deductible applies	$50 copayment	$30 copayment
Specialist	$95 copayment first 3 visits then deductible applies	$70 copayment	$35 copayment
Outpatient Surgery	60% coverage (after ded)	$1200 copayment	$600 copayment (per procedure)
Physical Therapy	$65 copayment	$50 copayment	$30 copayment
Inpatient Psych	60% coverage (after ded)	$750 per day (1st 4 days)	$600 per day per admit ($3000 max)
Outpatient Psych	$65 copayment first 3 visits then deductible applies	$50 copayment	$30 copayment
Rx Tier 1	$500 Rx ded then $18 ded per Rx	$15 copayment	$15 copayment
Rx Tier 2	$500 Rx ded then $500 max ben per Rx	$50 copay (after ded)	$50 copayment
Rx Tier 3	$500 Rx ded then $500 max ben per Rx	$70 copay (after ded)	$50 copayment
Rx Tier 4	$500 Rx ded then $500 max ben per Rx	60% cov up to $250 per 30 day script after Rx deductible	80% coverage to $250 max ben (ded waived)
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
	678.66	709.83	963.15
Total	48863.52	51107.76	69346.80