|  |
| Plan | Platinum 90 HMO 0/20 (shop) |
| Metal | Platinum |
| Network | Kaiser Permanente |
| Deductible | None |
| Coinsurance | Fixed copays for most services |
| Out of Pocket Mzx | $4500/$9000 family |
| Ambulance | $150 copayment |
| Chiropractor | Not covered |
| Durable Med Equip | 90% coverage |
| Emergency Room | $150 copay |
| Hospital | $250 per day 1st 5 days |
| Infertility | Optional |
| Lab & X-Ray | $20 lab/$30 X-ray |
| Office Visit | $20 copayment |
| Specialist | $30 copayment |
| Outpatient Surgery | $125 copayment (per procedure) |
| Physical Therapy | $20 copayment |
| Inpatient Psych | $250 per day 1st 5 days |
| Outpatient Psych | $20 copayment |
| Rx Tier 1 | $5 copayment |
| Rx Tier 2 | $20 copayment |
| Rx Tier 3 | $20 copayment |
| Rx Tier 4 | 90% cov up to $250 per Rx |
| Links | Brochure Formulary Providers |
| Evan Harris | 595.19 |
| Kevin Mathews | 509.84 |
| Manuel Maldonado | 520.62 |
| Wade Petrie | 470.76 |
| Total | 2096.41 |