|  |  | |
| Plan | Silver 70 HDHP PPO 1400/40% + Child Dental Alt (shop) | Silver 70 PPO 2250/50 w Child Dental (shop) | Gold 80 PPO 350/25 w Child Dental (shop) |
| Metal | Silver | Silver | Gold |
| Network | Full Network HMO | Full PPO Network | Full PPO Network |
| Deductible | $1400/$2800 family | $2250/$4500 family | $350/$700 family |
| Coinsurance | 60% coverage for most services | 70% coverage for most services | 80% coverage for most services |
| Out of Pocket Mzx | $7000/$14,000 family | $8200/$16,400 family | $7800/$15,600 family |
| Ambulance | 60% coverage (ded applies) | 70% coverage (after deductible) | 80% coverage |
| Chiropractor | Optional | Not covered | Not covered |
| Durable Med Equip | 60% coverage (ded applies) | 70% coverage (after deductible) | 80% coverage |
| Emergency Room | 60% coverage (ded applies) | 70% coverage (after deductible) | $250 copayment |
| Hospital | 60% coverage (ded applies) | 70% coverage (after deductible) | 80% coverage (after deductible) |
| Infertility | Optional | Not covered | Not covered |
| Lab & X-Ray | Lab: 60% coverage (ded applies)/X-ray 60% cov (ded applies) | $50 lab/$85 X-ray | $25 lab/$65 X-ray |
| Office Visit | 60% coverage (ded applies) | $50 copayment | $25 copayment |
| Specialist | 60% coverage (ded applies) | $85 copayment | $50 copayment |
| Outpatient Surgery | 60% coverage (ded applies) | 70% coverage (after deductible) | 80% coverage |
| Physical Therapy | 60% coverage | $50 copayment (after deductible) | $25 copayment |
| Inpatient Psych | 60% coverage (ded applies) | 70% coverage (after deductible) | 80% coverage (after deductible) |
| Outpatient Psych | 60% coverage (ded applies) | $50 copayment | $25 copayment |
| Rx Tier 1 | $19 copay after ded | $17 copayment | $15 copayment |
| Rx Tier 2 | $80 copayment (ded applies) | $70 copayment (after $300 Rx ded) | $50 copayment |
| Rx Tier 3 | $100 copayment (ded applies) | $100 copayment (after $300 Rxded) | $80 copayment |
| Rx Tier 4 | 60% coverage (up to $250 per 30 day script after ded) | 70% coverage up to $250 per Rx (after $300 Rxded) | 80% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Una | 807.65 fam 2447.11 | 865.06 fam 2621.05 | 975.13 fam 2954.55 |
| Total | 807.65 w deps 2447.11 | 865.06 w deps 2621.05 | 975.13 w deps 2954.55 |