|  | | |  |
| Plan | Silver Full PPO 1800/55 OffEx | Gold Full PPO 0/20 OffEx | Gold 80 PPO 250/25 Plus Child Dental | Gold PPO 20/30% 4HW6 |
| Metal | Silver | Gold | Gold | Gold |
| Network | Full PPO Network | Full PPO Network | Full PPO Network | Prudent Buyer PPO |
| Deductible | $1800/$3600 family | None | $250/$500 family | None |
| Coinsurance | 65% coverage for most services | 70% coverage for most services | 80% coverage for most services | 70% coverage for most services |
| Out of Pocket Mzx | $7800/$15,600 family | $7650/$15,300 family | $7800/$15,600 family | $7000/$14,000 family |
| Ambulance | 65% coverage (after deductible) | 70% coverage | $250 copayment | 70% coverage |
| Chiropractor | $15 per visit | Not covered | Not covered | Limited coverage |
| Durable Med Equip | 50% coverage (after deductible) | 50% coverage | 80% coverage | 50% coverage |
| Emergency Room | $350 per visit then 65% cov after ded | $250 copay then 70% coverage | $250 copayment | $250 copay then 70% coverage |
| Hospital | 65% coverage (after deductible) | 70% coverage | 80% coverage (after deductible) | 70% coverage |
| Infertility | Not covered | Not covered | Not covered | Not covered |
| Lab & X-Ray | Lab: $55 copay/X-ray: $80 | $20 lab/$50 X-ray | $25 lab/$65 X-ray | 50% coverage |
| Office Visit | $55 copayment | $20 copayment | $25 copayment | $20 copayment |
| Specialist | $80 copayment | $50 copayment | $50 copayment | $50 copayment |
| Outpatient Surgery | 65% coverage (after deductible) | $150 copayment (then 70% coverage) | 80% coverage (after deductible) | 70% coverage |
| Physical Therapy | 65% coverage (after deductible) | 70% coverage | $25 copayment | $20 copayment |
| Inpatient Psych | 65% coverage (after deductible) | 70% coverage | 80% coverage (after deductible) | 70% coverage |
| Outpatient Psych | $55 copayment | $20 copayment | $25 copayment | $20 copayment |
| Rx Tier 1 | $20 copayment | $15 copayment | $15 copayment | $15 copayment |
| Rx Tier 2 | $75 copayment (after $300 Rx ded) | $40 copayment | $50 copayment | $40 copayment |
| Rx Tier 3 | $115 copayment (after $300 Rx ded) | $60 copayment | $80 copayment | $150 copayment |
| Rx Tier 4 | 70% coverage up to $250 per Rx (after $300 Rx ded) | 70% coverage up to $250 per Rx | 80% coverage up to $250 per Rx | 70% coverage to $250 max after $250 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Catherine | 1059.98 | 1221.63 | 1261.36 | 1315.2 |
| Emily | 452.66 | 521.69 | 538.66 | 561.65 |
| Luke | 486.64 | 560.85 | 579.09 | 603.81 |
| Total | 1999.28 | 2304.17 | 2379.11 | 2480.66 |