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| Plan | Silver 70 HMO 2950/65 (shop) | Silver 70 HMO 2300/65 (shop) | Silver 70 HMO 1900/65 (shop) | Gold 80 HMO 1000/40 (shop) | Gold 80 HMO 250/35 (shop) | Gold 80 HMO 0/35 (shop) |
| Metal | Silver | Silver | Silver | Gold | Gold | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $2950/$5900 family | $2300/$4600 family | $1900/$3800 family | $1000 ($2000 family) | $250 ($500 family) | None |
| Coinsurance | 55% coverage for most services | 55% coverage for most services | 55% coverage for most services | Fixed copays for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $9100/18,200 family | $8750/17,500 family | $8750/17,500 family | $7800/15,600 family | $7800/15,600 family | $7500/15,000 family |
| Ambulance | 55% coverage (after ded) | 55% coverage (after ded) | 55% coverage (after ded) | $350 copayment (after ded) | $250 copay (after ded) | $250 copay (after ded) |
| Chiropractor | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | $35 copay (physician referral) | $15 copay (20 visits ann max) |
| Durable Med Equip | 65% coverage | 55% coverage (ded applies) | 55% coverage (after ded) | 80% coverage | 80% coverage (after ded) | 80% coverage (after ded) |
| Emergency Room | 55% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | $350 copayment | $250 copay (after ded) | $250 copay (after ded) |
| Hospital | 55% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days |
| Infertility | Optional | Optional | Optional | Optional | Optional | Optional |
| Lab & X-Ray | $30 lab after ded/$75 X-ray after ded | $30 lab/$75 X-ray after ded | $30 lab/$75 X-ray after ded | $30 lab/$60 X-ray | $35 lab/$55 X-ray | $30 lab/$40 X-ray |
| Office Visit | $65 copayment | $65 copayment | $65 copayment | $40 copayment | $35 copayment | $30 copayment |
| Specialist | $100 copayment | $100 copayment | $100 copayment | $60 copayment | $55 copayment | $50 copayment |
| Outpatient Surgery | 55% coverage (ded applies) | 65% coverage (after ded) | 55% coverage (after ded) | $350 copayment (ded applies) | $335 copay (after ded) | $320 copayment |
| Physical Therapy | $65 copayment | $55 copayment | $65 copayment | $40 copayment | $35 copayment | $30 copayment |
| Inpatient Psych | 55% coverage (ded applies) | 55% coverage (ded applies) | 55% coverage (after ded) | $600 per day 1st 5 days (ded applies) | $600 per day 1st 5 days | $600 per day 1st 5 days |
| Outpatient Psych | $65 copayment | $65 copayment | $65 copayment | $40 copayment | $35 copayment | $30 copayment |
| Rx Tier 1 | $20 copay | $20 copay | $20 copay | $20 copayment | $15 copayment | $15 copayment |
| Rx Tier 2 | $100 copay (after med ded) | $100 copay (after $500 Rx ded) | $100 copayment | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment |
| Rx Tier 3 | $100 copay (after med ded) | $100 copay (after $500 Rx ded) | $100 copayment | $50 copay (after $250 Rx ded) | $40 copayment | $50 copayment |
| Rx Tier 4 | 55% coverage to $250 (med ded applies) | 80% cov $250 max (after $370 Rx ded) | 80% cov $250 max ben (after medical ded) | 80% coverage to $250 (after $250 Rx ded) | 80% coverage to $250 | 80% coverage to $250 max |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Domingo Pedraza Pina | 446.12 | 461.96 | 471.2 | 544.9 | 572.98 | 591.23 |
| Gerardo Nateras Reye | 570.75 | 591 | 602.82 | 697.11 | 733.04 | 756.38 |
| Gilberto Garcia Rodr | 545.61 | 564.98 | 576.28 | 666.42 | 700.76 | 723.08 |
| Jorge Jasso Ramirez | 440.54 | 456.18 | 465.3 | 538.08 | 565.81 | 583.83 |
| Jose Guadalupe Jasso | 423.78 | 438.82 | 447.6 | 517.61 | 544.28 | 561.62 |
| Jose Ramon Rodriguez | 434.95 | 450.39 | 459.4 | 531.26 | 558.63 | 576.42 |
| Juan Diaz | 473.7 | 490.51 | 500.33 | 578.58 | 608.4 | 627.78 |
| Liliana Noriega Cama | 418.2 | 433.04 | 441.7 | 510.79 | 537.11 | 554.22 |
| Rene Antonio Giron R | 390.62 | 404.48 | 412.58 | 477.11 | 501.69 | 517.67 |
| new hire example | 404.58 | 418.94 | 427.32 | 494.16 | 519.63 | 536.18 |
| Total | 4548.85 | 4710.30 | 4804.53 | 5556.02 | 5842.33 | 6028.41 |