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| Plan | Bronze Full PPO 6850/55 OffEx | Bronze Full PPO Savings 7000 OffEx | Bronze Full PPO Savings 5700/40% OffEx | Silver Full PPO Savings 2600/35% OffEx | Silver Full PPO Savings 2300/30% OffEx | Silver Full PPO 2550/70 OffEx | Gold Full PPO Savings 1750/15 OffEx | Gold Full PPO 750/30 OffEx |
| Metal | Bronze | Bronze | Bronze | Silver | Silver | Silver | Gold | Gold |
| Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $6850/$13,800 family | $7500/$15,000 family | $5700/$11,400 family | $2600 or $3200/$5200 family | $2300 or $3200/$4600 family | $2550/$5100 family | $1750 or $3200/$3500 family | $750/$1500 family |
| Coinsurance | 65% coverage for most services | 100% coverage for most services | 60% coverage for most services | 65% coverage for most services | 70% coverage for most services | 60% coverage for most services | 85% coverage for most services | 80% coverage for most services |
| Out of Pocket Mzx | $9100/$18,200 family | $7500/$15,000 family | $7500/$15,000 family | $7900//$15,800 family | $7900//$15,800 family | $8750/$17,500 family | $4000/$8000 family | $8150/$16,100 family |
| Ambulance | 65% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | 60% coverage after ded | 85% coverage after ded | 80% coverage |
| Chiropractor | $15 per visit (20 visits max) | 100% coverage (after deductible) | 50% coverage after ded (20 visits max) | 65% coverage after ded(20 visits max) | 70% coverage after ded (20 visits max) | $15 per visit (20 visits max) | 85% coverage after ded (20 visits max) | $10 per visit (20 visits max) |
| Durable Med Equip | 50% coverage (after deductible) | 100% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage after ded | 50% coverage (after deductible) | 85% coverage after ded | 50% coverage |
| Emergency Room | 50% coverage (after deductible) | 100% coverage (after deductible) | $250 copayment (then 60% coverage) after ded | $150 copay then 65% cov after ded | 70% coverage after ded | $350 copay then 60% cov after ded | $150 per visit then 85% cov after ded | $250 copay after ded then 20% |
| Hospital | 65% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | 60% coverage after ded | 85% coverage after ded | 80% coverage after ded |
| Infertility | Optional | Optional | Optional | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | 65% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | Lab: $65 copay/X-ray: $85 | 85% coverage after ded | $30 lab/$50 X-ray |
| Office Visit | $55 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | $70 copayment | 85% coverage after ded | $30 copayment |
| Specialist | $75 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | $80 copayment | 85% coverage after ded | $55 copayment |
| Outpatient Surgery | 65% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | $150 copayment (then 65% coverage) after ded | 70% coverage after ded | 60% coverage after ded | 85% coverage after ded | 80% coverage after ded |
| Physical Therapy | $55 copayment after ded | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | 60% coverage after ded | 85% coverage after ded | 80% coverage after ded |
| Inpatient Psych | $55 copayment (after ded) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | $70 copayment | 85% coverage after ded | $30 copayment |
| Outpatient Psych | 65% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after deductible) | 65% coverage after ded | 70% coverage after ded | 60% coverage after ded | 85% coverage after ded | 80% coverage after ded |
| Rx Tier 1 | $20 copay | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | 65% cov up to $250 per Rx after ded | $25 copayment after ded | $25 copayment | $10 copayment after ded | $10 copayment |
| Rx Tier 2 | $65 copay (after $650 Rx ded) | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | 65% cov up to $250 per Rx after ded | $75 copayment after ded | $75 copayment (after $300 Rx ded) | $30 copayment after ded | $40 copayment (after $250 Rx ded) |
| Rx Tier 3 | $90 copay (after $650 Rx ded) | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | 65% cov up to $250 per Rx after ded | $100 copay (after ded) | $115 copayment (after $300 Rx ded) | $50 copay (after ded) | $70 copayment |
| Rx Tier 4 | 70% coverage up to $500 per Rx after $650 Rx ded | 100% coverage (after deductible) | 60% coverage up to $500 per Rx after ded | 65% cov up to $250 per Rx after ded | 70% coverage up to $250 per Rx after ded | 60% coverage up to $500 per Rx (after $300 Rx ded) | 70% coverage up to $250 per Rx after ded | 70% cov after $100 Rx ded 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 | Brochure Formulary Providers |
| Alexander Aslanian | 526.13 | 535.83 | 540.27 | 545.29 | 558.64 | 590.46 | 642.47 | 665.71 |
| Bryce Adams | 560.98 | 571.32 | 576.06 | 581.41 | 595.64 | 629.57 | 685.03 | 709.81 |
| Jeff Hess | 987.4 fam 1932.21 | 1005.6 fam 1967.82 | 1013.94 fam 1984.14 | 1023.37 fam 2002.59 | 1048.42 fam 2051.61 | 1108.13 fam 2168.46 | 1205.74 fam 2359.47 | 1249.36 fam 2444.82 |
| Matthew Hutton | 591.47 | 602.37 | 607.37 | 613.02 | 628.02 | 663.79 | 722.26 | 748.39 |
| Rick Franke | 864.46 fam 2902.18 | 880.39 fam 2955.67 | 887.7 fam 2980.2 | 895.95 fam 3007.9 | 917.88 fam 3081.53 | 970.16 fam 3257.03 | 1055.62 fam 3543.95 | 1093.8 fam 3672.14 |
| Total | 3530.44 w deps 6512.97 | 3595.51 w deps 6633.01 | 3625.34 w deps 6688.04 | 3659.04 w deps 6750.21 | 3748.60 w deps 6915.44 | 3962.11 w deps 7309.31 | 4311.12 w deps 7953.18 | 4467.07 w deps 8240.87 |