Prepared for Synergy StaffingZip code 90040Eff date 5/2023

Plan	Gold 80 HMO 0/30 (shop)	Bronze 60 PPO 6300/65 w Child Dental (shop)	Platinum 90 HMO 0/20 (shop)	Platinum 90 HMO 0/10 (shop)	Silver 70 PPO 2500/55 w Child Dental (shop)	Gold 80 PPO 350/25 w Child Dental (shop)	Platinum 90 PPO 0/15 w Child Dental (shop)
Metal	Gold	Bronze	Platinum	Platinum	Silver	Gold	Platinum
Network	Kaiser Permanente	Full PPO Network	Kaiser Permanente	Kaiser Permanente	Full PPO Network	Full PPO Network	Full PPO Network
Deductible	None	$6300/$12,600 family	None	None	$2500/$5000 family	$350/$700 family	None
Coinsurance	Fixed copays for most services	60% coverage for most services	Fixed copays for most services	Fixed copays for most services	65% coverage for most services	80% coverage for most services	90% coverage for most services
Out of Pocket Mzx	$7500/15,000 family	$8200/$16,400 family	$4500/$9000 family	$3000/$6000 family	$8600/$17,200 family	$7800/$15,600 family	$4500/9000 family
Ambulance	$250 copayment (after ded)	60% coverage (after deductible)	$150 copayment	$150 copayment	65% coverage (after deductible)	80% coverage	$150 copayment
Chiropractor	$15 copay (20 visits ann max)	Not covered	Not covered	$15 copay (20 visits ann max)	Not covered	Not covered	Not covered
Durable Med Equip	80% coverage (after ded)	60% coverage (after deductible)	90% coverage	90% coverage	65% coverage (after deductible)	80% coverage	90% coverage
Emergency Room	$250 copayment (after ded)	60% coverage (after deductible)	$150 copay	$200 copay	65% coverage (after deductible)	80% coverage	$200 copayment
Hospital	$600 per day 1st 5 days	60% coverage (after deductible)	$250 per day 1st 5 days	$500 per admission	65% coverage (after deductible)	80% coverage (after deductible)	90% coverage
Infertility	Optional	Not covered	Optional	Optional	Not covered	Not covered	Not covered
Lab & X-Ray	$30 lab/$40 X-ray	$40 lab/X-ray 60% after ded	$20 lab/$30 X-ray	$20 lab/$40 X-ray	$55 lab/$90 X-ray	$25 lab/$65 X-ray	Lab $15 copay / X-ray $30 copay
Office Visit	$30 copayment	$65 copayment	$20 copayment	$10 copayment	$55 copayment	$25 copayment	$15 copayment
Specialist	$50 copayment	$95 copayment	$30 copayment	$20 copayment	$90 copayment	$50 copayment	$30 copayment
Outpatient Surgery	$320 copayment	60% coverage (after deductible)	$125 copayment (per procedure)	$300 copayment (per procedure)	65% coverage (after deductible)	80% coverage	90% coverage
Physical Therapy	$30 copayment	$65 copayment	$20 copayment	$10 copayment	$55 copayment (after deductible)	$25 copayment	$15 copayment
Inpatient Psych	$600 per day 1st 5 days	60% coverage (after deductible)	$250 per day 1st 5 days	$500 per admission	60% coverage (after deductible)	80% coverage (after deductible)	90% coverage
Outpatient Psych	$30 copayment	$65 copayment	$20 copayment	$10 copayment	$55 copayment	$25 copayment	$15 copayment
Rx Tier 1	$15 copayment	$18 copay after ded (after $500 Rx ded)	$5 copayment	$5 copayment	$25 copayment	$15 copayment	$10 copayment
Rx Tier 2	$50 copayment	60% coverage up to $500 per Rx (after $500 Rx ded)	$20 copayment	$15 copayment	$75 copayment (after $300 Rx ded)	$50 copayment	$25 copayment
Rx Tier 3	$50 copayment	60% coverage up to $500 per Rx (after $500 Rx ded)	$20 copayment	$15 copayment	$105 copayment (after $300 Rxded)	$80 copayment	$40 copayment
Rx Tier 4	80% coverage to $250 max	60% coverage up to $500 per Rx (after $500 Rx ded)	90% cov up to $250 per Rx	90% cov up to $250 per Rx	70% coverage up to $250 per Rx (after $300 Rxded)	80% coverage up to $250 per Rx	90% coverage (up to $250 per Rx)
Links	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers	Brochure Formulary Providers
Tarek M	461.48	468.66	487.51	496.42	537.29	615.02	685.78
Vladimir L.	742.59	754.15	784.47	798.82	864.58	989.66	1103.52
Total	1204.07	1222.81	1271.98	1295.24	1401.87	1604.68	1789.30