Prepared for Stainless EquipmentZip code 91786Eff date 8/2020

Plan	WholeCare HMO Silver $50	WholeCare HMO Gold $50	WholeCare HMO Gold $40	WholeCare HMO Gold $35	WholeCare HMO Platinum $30	WholeCare HMO Gold $30	WholeCare HMO Platinum $20	WholeCare HMO Platinum $10
Metal	Silver	Gold	Gold	Gold	Platinum	Gold	Platinum	Platinum
Network	WholeCare HMO	WholeCare HMO	WholeCare HMO	WholeCare HMO	WholeCare HMO	WholeCare HMO	WholeCare HMO	WholeCare HMO
Deductible	None	None	None	None	None	None	None	None
Coinsurance	50% coverage for most services	60% coverage for most services	60% coverage for most services	70% coverage for most services	70% coverage for most services	70% coverage for most services	80% coverage for most services	90% coverage for most services
Out of Pocket Mzx	$7800/$15,600 family	$7000,$14,000 family	$6500/$13,000 family	$6000/$12,000 family	$2250/$4500 family	$6000/$12,000 family	$3000/$6000 family	$2500/$5000 family
Ambulance	50% coverage	$300 copayment	$300 copayment	$300 copayment	$100 copayment	$300 copayment	$150 copaymet	$100 copayment
Chiropractor	Optional	Optional	Optional	Optional	Optional	Optional	Optional	Optional
Durable Med Equip	50% coverage	60% coverage	60% coverage	70% coverage	70% coverage	70% coverage	80% coverage	90% coverage
Emergency Room	50% coverage	$300 copayment	$300 copayment	$300 copayment	$250 copayment	$300 copayment	$150 copaymet	$100 copayment
Hospital	50% coverage	$750 per day (1st 4 days)	$750 per day (1st 3 days)	$750 per day (1st 3 days)	$500 per day (1st 4 days)	$750 per day (1st 3 days)	$350 per day (1st 3 days)	$250 per day (1st 3 days)
Infertility	Optional	Optional	Optional	Optional	Optional	Optional	Optional	Optional
Lab & X-Ray	Lab: $40 copay/X-ray $50 copay	Lab: $40 copay/X-ray $50 copay	Lab: $40 copay/X-ray $40 copay	Lab: $40 copay/X-ray $50 copay	Lab: $20 copay/X-ray $50 copay	Lab: $40 copay/X-ray $40 copay	Lab: $10 copay/X-ray $10 copay	Lab: $10 copay/X-ray $10 copay
Office Visit	$50 copayment	$50 copayment	$40 copayment	$35 copayment	$30 copayment	$30 copayment	$20 copayment	$10 copayment
Specialist	$70 copayment	$70 copayment	$60 copayment	$55 copayment	$50 copayment	$50 copayment	$40 copayment	$30 copayment
Outpatient Surgery	50% coverage	$1200 copayment	$1100 copayment	$1200 copayment	$150 copayment	$900 copayment	$500 copayment	$100 copayment
Physical Therapy	$50 copayment	$50 copayment	$40 copayment	$35 copayment	$30 copayment	$30 copayment	$20 copayment	$10 copayment
Inpatient Psych	50% coverage	$750 per day (1st 4 days)	$750 per day (1st 3 days)	$750 per day (1st 3 days)	$500 per day (1st 4 days)	$750 per day (1st 3 days)	$350 per day (1st 3 days)	$250 per day (1st 3 days)
Outpatient Psych	$50 copayment	$50 copayment	$40 copayment	$35 copayment	$30 copayment	$30 copayment	$20 copayment	$10 copayment
Rx Tier 1	$20 copayment	$15 copayment	$5 copayment	$5 copayment	$5 copayment	$5 copayment	$5 copayment	$5 copayment
Rx Tier 2	50% (up to $250 per 30 day script after Rx ded)	$50 copay (after ded)	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment
Rx Tier 3	50% (up to $250 per 30 day script after Rx ded)	$70 copay (after ded)	$50 copayment	$50 copayment	$50 copayment	$50 copayment	$50 copayment	$50 copayment
Rx Tier 4	50% cov up to $250 per 30 day script after Rx deductible	60% cov up to $250 per 30 day script after Rx deductible	70% cov ($250 max per 30 day script)	70% cov ($250 max per 30 day script)	70% cov ($250 max per 30 day script)	30% (up to $250 per 30 day script after ded)	70% cov ($250 max per 30 day script)	70% cov ($250 max per 30 day script)
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
Cesar	537.69	549.18	557.73	566.25	577.41	579.59	595.17	643.37
Irma Castellanos	398.9	407.42	413.77	420.09	428.37	429.99	441.54	477.3
Total	936.59	956.60	971.50	986.34	1005.78	1009.58	1036.71	1120.67