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| Plan | Silver 70 HMO 2600/55 (shop) | Silver 70 HMO 2100/55 (shop) | Silver 70 HMO 2250/55 (shop) | Silver 70 HMO 1650/55 (shop) | Trio Silver 70 HMO 2250/55 w Child Dental (shop) | Gold 80 HMO 0/30 (shop) | Trio Gold 80 HMO 250/35 w Child Dental (shop) | Silver 70 Value PPO 1700/50 + Child Dental Alt (shop) | Silver 70 HDHP PPO 1400/40% + Child Dental Alt (shop) | Silver 70 PPO 2250/50 w Child Dental (shop) | Silver 70 PPO 2250/50 + Child Dental (shop) | Gold 80 Value PPO 750/15 + Child Dental Alt (shop) | Gold 80 PPO 350/25 w Child Dental (shop) | Gold 80 PPO 0/30 + Child Dental Alt (shop) | Gold 80 PPO 350/25 + Child Dental (shop) |
| Metal | Silver | Silver | Silver | Silver | Silver | Gold | Gold | Silver | Silver | Silver | Silver | Gold | Gold | Gold | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Trio ACO Network | Kaiser Permanente | Trio ACO Network | Full Network HMO | Full Network HMO | Full PPO Network | Full Network HMO | Full Network HMO | Full PPO Network | Full Network HMO | Full Network HMO |
| Deductible | $2600/$5200 family | $2100/$4200 family | $2250/$4500 family | $1650/$3300 family | $2250/$4500 family | None | $250/$500 family | $1700/$3400 family | $1400/$2800 family | $2250/$4500 family | $2250/$4500 family | $750/$1500 family | $350/$700 family | None | $350/$700 family |
| Coinsurance | 55% coverage for most services | 55% coverage for most services | 70% coverage for most services | 60% coverage for most services | 80% coverage for most services | Fixed copays for most services | Fixed copays 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 | 70% coverage for most services | 80% coverage for most services |
| Out of Pocket Mzx | $8200/16,400 family | $8200/16,400 family | $8200/16,400 family | $8200/16,400 family | $8200/$16,400 family | $7000/14,000 family | $7800/$15,600 family | $8000/$16,000 family | $7000/$14,000 family | $8200/$16,400 family | $8200/$16,400 family | $7800/$15,600 family | $7800/$15,600 family | $7600/$15,200 family | $7800/$15,600 family |
| Ambulance | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | 70% coverage (after ded) | $250 copayment (after ded) | $250 copayment | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | $250 copayment (ded applies) | 80% coverage | 70% coverage | 80% coverage (ded waived) |
| Chiropractor | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Not covered | Optional | Optional | Not covered | Optional | Optional | Not covered | Optional | Optional |
| Durable Med Equip | 55% coverage | 55% coverage | 70% coverage | 60% coverage (after ded) | 70% coverage (ded waived) | 80% coverage (after ded) | 80% coverage | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | 70% coverage (ded applies) | 80% coverage | 70% coverage | 80% coverage (ded waived) |
| Emergency Room | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | 70% coverage (after ded) | $250 copayment (after ded) | $250 copayment | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | $250 copayment (ded applies) | $250 copayment | 70% coverage | 80% coverage (ded waived) |
| Hospital | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | 70% coverage (after ded) | $600 per day 1st 5 days | $600 per day 1st 5 days | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | 70% coverage (ded applies) | 80% coverage (after deductible) | 70% coverage | 80% coverage (ded applies) |
| Infertility | Optional | Optional | Optional | Optional | Not covered | Optional | Not covered | Optional | Optional | Not covered | Optional | Optional | Not covered | Optional | Optional |
| Lab & X-Ray | $30 lab/$75 X-ray | $30 lab/$75 X-ray | $55 lab/$90 X-ray | $30 lab/$75 X-ray after ded | $55 lab/$90 X-ray | $30 lab/$40 X-ray | $35 lab/$55 X-ray | Lab: $40 copay (ded applies)/X-ray $50 copay(ded applies) | Lab: 60% coverage (ded applies)/X-ray 60% cov (ded applies) | $50 lab/$85 X-ray | Lab: $50 copay (ded waived)/X-ray $85 copay (ded waived) | Lab: $25 copay (ded waived)/X-ray $25 copay (ded waived) | $25 lab/$65 X-ray | Lab: $30 copay/X-ray $40 copay | Lab: $25 copay (ded waived)/X-ray $65 copay (ded waived) |
| Office Visit | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $30 copayment | $25 copayment | $50 copayment | 60% coverage (ded applies) | $50 copayment | $50 copayment | $15 copayment | $25 copayment | $30 copayment | $25 copayment |
| Specialist | $80 copayment | $80 copayment | $90 copayment | $80 copayment | $90 copayment | $35 copayment | $65 copayment | $75 copayment | 60% coverage (ded applies) | $85 copayment | $85 copayment | $30 copayment | $50 copayment | $50 copayment | $50 copayment |
| Outpatient Surgery | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | 70% coverage (after ded) | $320 copayment | $300 copayment | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | 70% coverage (ded applies) | 80% coverage | 70% coverage | 80% coverage (ded waived) |
| Physical Therapy | $65 copayment | $65 copayment | $55 copayment | $65 copayment | $55 copayment | $30 copayment | $25 copayment | $50 copayment | 60% coverage | $50 copayment (after deductible) | 70% coverage (ded applies) | $15 copayment | $25 copayment | $30 copayment | $25 copayment |
| Inpatient Psych | 55% coverage (ded applies) | 55% coverage (after ded) | 70% coverage (ded applies) | 60% coverage (after ded) | 70% coverage (after ded) | $600 per day 1st 5 days | $600 per day 1st 5 days | 60% coverage (ded applies) | 60% coverage (ded applies) | 70% coverage (after deductible) | 70% coverage (ded applies) | 70% coverage (ded applies) | 80% coverage (after deductible) | 70% coverage | 80% coverage (ded applies) |
| Outpatient Psych | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $55 copayment | $30 copayment | $25 copayment | $50 copayment | 60% coverage (ded applies) | $50 copayment | $50 copayment | $15 copayment | $25 copayment | $30 copayment | $25 copayment |
| Rx Tier 1 | $20 copay | $20 copay | $500 Rx ded then $17 ded per Rx | $20 copay | $17 copayment (after $300 Rxd ed) | $15 copayment | $15 copayment | $19 copayment | $19 copay after ded | $17 copayment | $17 copay | $15 copayment | $15 copayment | $15 copayment | $15 copayment |
| Rx Tier 2 | $75 copay (after med ded) | $75 copay (after $500 Rx ded) | $65 copay (after $300 Rx ded) | $75 copay (after $350 Rx ded) | $80 copayment (after $300 Rx ded) | $40 copayment | $40 copayment | $65 copayment (ded applies) | $80 copayment (ded applies) | $70 copayment (after $300 Rx ded) | $70 copayment after $300 Rx ded | $40 copayment (ded applies) | $50 copayment | $40 copayment | $50 copayment |
| Rx Tier 3 | $75 copay (after med ded) | $75 copay (after $500 Rx ded) | $65 copay (after $300 Rx ded) | $75 copay (after $350 Rx ded) | $110 copayment (after $300 Rxded) | $40 copayment | $70 copayment | $100 copayment (ded applies) | $100 copayment (ded applies) | $100 copayment (after $300 Rxded) | $100 copayment after $300 Rx ded | $70 copayment (ded applies) | $80 copayment | $70 copayment | $80 copayment |
| Rx Tier 4 | 55% coverage to $250 (plan ded applies) | 80% cov $250 max (after $500 Rx ded) | 80% cov $250 max ben (after $300 Rx ded) | 80% cov $250 max ben (after $350 Rx ded) | 70% coverage up to $250 per Rx (after $300 Rxded) | 80% coverage to $250 max | 80% coverage up to $250 per Rx | 60% coverage (up to $250 per Rx after ded) | 60% coverage (up to $250 per 30 day script after ded) | 70% coverage up to $250 per Rx (after $300 Rxded) | 70% coverage (up to $250 per Rx after $300 Rx ded) | 70% coverage (up to $250 per Rx after ded) | 80% coverage up to $250 per Rx | 70% cov ($250 max per 30 day script) | 80% coverage ($250 max per 30 day script) |
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| Ahlam Mohammed | 315.29 | 320.66 | 324.27 | 326.59 | 348.88 | 404.57 | 417.03 | 417.67 | 425.67 | 453.96 | 479.67 | 489.93 | 511.72 | 530.41 | 578.81 |
| Alejandra Valdez | 535.74 | 544.86 | 551 | 554.94 | 592.82 | 687.45 | 708.62 | 709.71 | 723.29 | 771.37 | 815.06 | 832.49 | 869.51 | 901.28 | 983.51 |
| Alejandra Valdez | 535.74 fam 1745.9 | 544.86 fam 1774.92 | 551 fam 1794.45 | 554.94 fam 1806.99 | 592.82 fam 1885.48 | 687.45 fam 2228.43 | 708.62 fam 2253.8 | 709.71 fam 2257.27 | 723.29 fam 2300.46 | 771.37 fam 2453.37 | 815.06 fam 2592.33 | 832.49 fam 2647.78 | 869.51 fam 2765.52 | 901.28 fam 2866.55 | 983.51 fam 3128.09 |
| Andrea Chisom | 321.57 | 327.05 | 330.73 | 333.1 | 355.83 | 412.63 | 425.34 | 425.99 | 434.15 | 463 | 489.23 | 499.69 | 521.91 | 540.98 | 590.34 |
| Angela Yoon Chang | 453.46 | 461.18 | 466.38 | 469.72 | 501.78 | 581.87 | 599.79 | 600.72 | 612.21 | 652.9 | 689.89 | 704.64 | 735.98 | 762.87 | 832.47 |
| Cherly Weaver | 416.09 | 423.18 | 427.95 | 431.01 | 460.42 | 533.92 | 550.37 | 551.21 | 561.76 | 599.1 | 633.03 | 646.57 | 675.33 | 700 | 763.86 |
| Christine Asha Mays | 438.7 | 446.17 | 451.2 | 454.43 | 485.44 | 562.94 | 580.27 | 581.17 | 592.29 | 631.65 | 667.43 | 681.71 | 712.02 | 738.04 | 805.37 |
| Eric Dillie | 408.87 | 415.83 | 420.52 | 423.53 | 452.43 | 524.65 | 540.81 | 541.65 | 552.01 | 588.7 | 622.04 | 635.35 | 663.6 | 687.85 | 750.6 |
| Helen Huang | 356.42 | 362.5 | 366.58 | 369.2 | 394.4 | 457.36 | 471.44 | 472.17 | 481.21 | 513.19 | 542.26 | 553.86 | 578.49 | 599.62 | 654.33 |
| Herman Tse | 321.57 | 327.05 | 330.73 | 333.1 | 355.83 | 412.63 | 425.34 | 425.99 | 434.15 | 463 | 489.23 | 499.69 | 521.91 | 540.98 | 590.34 |
| Jasmine Fajardo | 314.03 | 319.38 | 322.98 | 325.29 | 347.49 | 402.96 | 415.37 | 416.01 | 423.97 | 452.15 | 477.76 | 487.98 | 509.68 | 528.3 | 576.5 |
| Jessica Esqivel | 363.96 | 370.16 | 374.33 | 377.01 | 402.74 | 467.03 | 481.41 | 482.16 | 491.38 | 524.04 | 553.72 | 565.57 | 590.72 | 612.3 | 668.16 |
| Koula Laventis | 535.74 | 544.86 | 551 | 554.94 | 592.82 | 687.45 | 708.62 | 709.71 | 723.29 | 771.37 | 815.06 | 832.49 | 869.51 | 901.28 | 983.51 |
| Krista Kastriotis | 408.87 | 415.83 | 420.52 | 423.53 | 452.43 | 524.65 | 540.81 | 541.65 | 552.01 | 588.7 | 622.04 | 635.35 | 663.6 | 687.85 | 750.6 |
| Kristine Nguyen | 315.29 | 320.66 | 324.27 | 326.59 | 348.88 | 404.57 | 417.03 | 417.67 | 425.67 | 453.96 | 479.67 | 489.93 | 511.72 | 530.41 | 578.81 |
| Luzmin Abellon | 852.28 | 866.8 | 876.57 | 882.84 | 943.09 | 1093.63 | 1127.31 | 1129.05 | 1150.65 | 1227.14 | 1296.64 | 1324.38 | 1383.27 | 1433.81 | 1564.62 |
| Nesreen Albanna | 315.29 | 320.66 | 324.27 | 326.59 | 348.88 | 404.57 | 417.03 | 417.67 | 425.67 | 453.96 | 479.67 | 489.93 | 511.72 | 530.41 | 578.81 |
| Tiffani Kastriotis | 396.31 | 403.06 | 407.6 | 410.52 | 438.53 | 508.54 | 524.2 | 525 | 535.05 | 570.61 | 602.93 | 615.83 | 643.22 | 666.71 | 727.54 |
| Total | 7605.22 w deps 8815.38 | 7734.75 w deps 8964.81 | 7821.90 w deps 9065.35 | 7877.87 w deps 9129.92 | 8415.51 w deps 9708.17 | 9758.87 w deps 11299.85 | 10059.41 w deps 11604.59 | 10074.91 w deps 11622.47 | 10267.72 w deps 11844.89 | 10950.17 w deps 12632.17 | 11570.39 w deps 13347.66 | 11817.88 w deps 13633.17 | 12343.42 w deps 14239.43 | 12794.38 w deps 14759.65 | 13961.69 w deps 16106.27 |