|  |  |  |
| Plan | Bronze 60 HMO 6300/65 (shop) | Bronze 60 PPO 6300/65 Plus Child Dental | Bronze 60 PPO 6300/65 + Child Dental (shop) |
| Metal | Bronze | Bronze | Bronze |
| Network | Kaiser Permanente | Full PPO Network | Full PPO |
| Deductible | $6300/$12,600 family | $6300/$12,600 family | $6300/$12,600 family |
| Coinsurance | 60% coverage for most services | 60% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $7800/15,600 family | $7800/$15,600 family | $7800/$15,600 family |
| Ambulance | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Chiropractor | Not covered | Not covered | Optional |
| Durable Med Equip | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Emergency Room | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Hospital | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Infertility | Optional | Not covered | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) | $40 lab/X-ray 60% after ded | Lab: $40 copay (ded waived)/X-ray 60% cov (ded applies) |
| Office Visit | $65 copayment first 3 visits then deductible applies | $65 copayment | $65 copay 1st 3 visits then ded applies |
| Specialist | $95 copayment first 3 visits then deductible applies | $95 copayment | $95 copay 1st 3 visits then ded applies |
| Outpatient Surgery | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Physical Therapy | $65 copayment | $65 copayment | $65 copayment |
| Inpatient Psych | 60% coverage (after ded) | 60% coverage (after deductible) | 60% coverage (ded applies) |
| Outpatient Psych | $65 copayment first 3 visits then deductible applies | $65 copayment | $65 copay 1st 3 visits then ded applies |
| Rx Tier 1 | $500 Rx ded then $18 ded per Rx | $500 Ann ded then$18 deductible per Rx | $18 copay (ded applies) |
| Rx Tier 2 | $500 Rx ded then $500 max ben per Rx | $500 Ann ded then$500 60% to $500 per Rx | 60% cov up to $500 per Rx after Rx ded |
| Rx Tier 3 | $500 Rx ded then $500 max ben per Rx | $500 Ann ded then$500 60% to $500 per Rx | 60% cov up to $500 per Rx after Rx ded |
| Rx Tier 4 | $500 Rx ded then $500 max ben per Rx | $500 Ann ded then$500 60% to $500 per Rx | 60% coverage (up to $500 per 30 day script after Rx ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Adrian Valencia | 220.45 | 323.11 | 427.4 |
| Alexis Flores | 271.52 | 397.97 | 526.42 |
| Bianca Hernandez | 234.27 | 343.37 | 454.2 |
| Ezekial Barrera | 234.27 | 343.37 | 454.2 |
| Haley Sills | 239.89 | 351.61 | 465.1 |
| Jazmine Salgado | 227.24 | 333.07 | 440.57 |
| Jimmy Brown Jr | 288.15 | 422.35 | 558.67 |
| Karla Roacho-Cota | 254.65 | 373.24 | 493.72 |
| Sairet Apolinar | 234.27 | 343.37 | 454.2 |
| Stephanie Acuna | 235.21 | 344.74 | 456.02 |
| Yaritza Garcia | 235.21 | 344.74 | 456.02 |
| Total | 2675.13 | 3920.94 | 5186.52 |