|  |  |
| Plan | Gateway 2600 Gold 80 HDHP HMO | Gold 80 HDHP HMO 1750/15 (shop) |
| Metal | Gold | Gold |
| Network | HMO Network | Kaiser Permanente |
| Deductible | $$2600 or $3300/$5200 family | $1750 or $3500/$3300 family |
| Coinsurance | 100% coverage for most services | 85% coverage for most services |
| Out of Pocket Mzx | $4800/$9600 family | $4000/$8000 family |
| Ambulance | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Chiropractor | 100% coverage (after deductible) (20 visits max) | $15 copay (physciain referral) |
| Durable Med Equip | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Emergency Room | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Hospital | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Infertility | Optional | Optional |
| Lab & X-Ray | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Office Visit | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Specialist | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Outpatient Surgery | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Physical Therapy | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Inpatient Psych | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Outpatient Psych | 100% coverage (after deductible) | 85% coverage (ded applies) |
| Rx Tier 1 | 100% coverage (after deductible) | $15 copay (med ded applies) |
| Rx Tier 2 | 100% coverage (after deductible) | $45 copay (med ded applies) |
| Rx Tier 3 | 100% coverage (after deductible) | $45 copay (med ded applies) |
| Rx Tier 4 | 100% coverage (after deductible) | 85% cov $250 max ben (after med ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Brenda Novak | 1086.43 | 1180.37 |
| Total | 1086.43 | 1180.37 |