|  | |  | | | |
| Plan | Gold 80 HDHP HMO 1600/15 | Gold 80 HMO 1000/40 | Trio Gold 80 HMO 250/35 w Child Dental (shop) | Gold 80 HMO 250/35 | Gold 80 HMO 0/30 (shop) | Gold 80 PPO 350/25 w Child Dental (shop) |
| Metal | Gold | Gold | Gold | Gold | Gold | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Trio ACO Network | Kaiser Permanente | Kaiser Permanente | Full PPO Network |
| Deductible | $1600 or $3000/$3200 family | $1000 ($2000 family) | $250/$500 family | $250 ($500 family) | None | $350/$700 family |
| Coinsurance | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services | 80% coverage for most services |
| Out of Pocket Mzx | $3550/$7100 family | $7800/15,600 family | $7800/$15,600 family | $7800/15,600 family | $7500/15,000 family | $7800/$15,600 family |
| Ambulance | 85% coverage (ded applies) | $350 copayment (after ded) | $250 copayment | $250 copayment (after ded) | $250 copayment (after ded) | 80% coverage |
| Chiropractor | Not covered | $15 copay (20 visits ann max) | Not covered | Not covered | $15 copay (20 visits ann max) | Not covered |
| Durable Med Equip | 85% coverage (ded applies) | 80% coverage | 80% coverage | 80% coverage (after ded) | 80% coverage (after ded) | 80% coverage |
| Emergency Room | 85% coverage (ded applies) | $350 copayment (after ded) | $250 copayment | $250 copayment (after ded) | $250 copayment (after ded) | 80% coverage |
| Hospital | 85% coverage (ded applies) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $600 per day 1st 5 days | 80% coverage (after deductible) |
| Infertility | Optional | Optional | Not covered | Optional | Optional | Not covered |
| Lab & X-Ray | 85% coverage (ded applies) | $30 lab/$60 X-ray | $35 lab/$55 X-ray | $35 lab/$55 X-ray | $30 lab/$40 X-ray | $25 lab/$65 X-ray |
| Office Visit | 85% coverage (ded applies) | $40 copayment | $35 copayment | $35 copayment | $30 copayment | $25 copayment |
| Specialist | 85% coverage (ded applies) | $60 copayment | $55 copayment | $55 copayment | $50 copayment | $50 copayment |
| Outpatient Surgery | 85% coverage (ded applies) | $350 copayment (ded applies) | $300 copayment | $335 copayment | $320 copayment | 80% coverage |
| Physical Therapy | 85% coverage (ded applies) | $40 copayment | $35 copayment | $35 copayment | $30 copayment | $25 copayment |
| Inpatient Psych | 85% coverage (ded applies) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days | $600 per day 1st 5 days | 80% coverage (after deductible) |
| Outpatient Psych | 85% coverage (ded applies) | $40 copayment | $25 copayment | $35 copayment | $30 copayment | $25 copayment |
| Rx Tier 1 | $15 copay (med ded applies) | $20 copayment | $15 copayment | $15 copayment | $15 copayment | $15 copayment |
| Rx Tier 2 | $45 copay (med ded applies) | $50 copay (after $250 Rx ded) | $40 copayment | $40 copayment | $50 copayment | $50 copayment |
| Rx Tier 3 | $45 copay (med ded applies) | $50 copay (after $250 Rx ded) | $70 copayment | $40 copayment | $50 copayment | $80 copayment |
| Rx Tier 4 | 85% cov $250 max ben (after med ded) | 80% coverage to $250 (after $250 Rx ded) | 80% coverage up to $250 per Rx | 80% coverage to $250 | 80% coverage to $250 max | 80% 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 |
| Anita Bailey | 457.71 | 494.75 | 520.79 | 526.14 | 553.62 | 782.03 |
| Brenda Houston-Harri | 1037.75 | 1121.73 | 1180.77 | 1192.9 | 1255.22 | 1773.09 |
| Courtney Franklin | 435.21 fam 1001.05 | 470.43 fam 1079.79 | 495.19 fam 1107.17 | 500.28 fam 1146.53 | 526.41 fam 1204.96 | 743.59 fam 1662.57 |
| Damien Danielly | 449.27 fam 1015.11 | 485.63 fam 1094.99 | 511.19 fam 1123.17 | 516.44 fam 1162.69 | 543.42 fam 1221.97 | 767.62 fam 1686.6 |
| DeVon Walker | 407.43 | 440.41 | 463.59 | 468.35 | 492.82 | 696.14 |
| Dominique Beaumonte | 477.04 | 515.65 | 542.79 | 548.36 | 577.01 | 815.07 |
| Eric Mayes | 599.73 fam 2041.18 | 648.26 fam 2202.97 | 682.38 fam 2274.74 | 689.39 fam 2340.08 | 725.41 fam 2460.14 | 1024.69 fam 3415.83 |
| Eugene Adams | 750.54 | 811.28 | 853.98 | 862.75 | 907.82 | 1282.37 |
| Myia Williams | 421.14 | 455.23 | 479.19 | 484.11 | 509.4 | 719.57 |
| Rashall HighTower | 527.31 fam 1203.95 | 569.99 fam 1300.26 | 599.99 fam 1353.97 | 606.15 fam 1381.87 | 637.82 fam 1453.33 | 900.96 fam 2033.17 |
| Trelisa Glasatov | 627.85 | 678.66 | 714.38 | 721.72 | 759.43 | 1072.74 |
| Total | 6190.98 w deps 9440.75 | 6692.02 w deps 10195.72 | 7044.24 w deps 10614.54 | 7116.59 w deps 10835.50 | 7488.38 w deps 11395.72 | 10577.87 w deps 15939.18 |