|  | |  | |
| Plan | Bronze 60 HMO 5400/60 (shop) | Silver 70 HMO 2600/55 (shop) | Bronze 60 PPO 6300/65 w Child Dental (shop) | Silver 70 PPO 2250/50 w Child Dental (shop) |
| Metal | Bronze | Silver | Bronze | Silver |
| Network | Kaiser Permanente | Kaiser Permanente | Full PPO Network | Full PPO Network |
| Deductible | $5400/$10,800 family | $2600/$5200 family | $6300/$12,600 family | $2250/$4500 family |
| Coinsurance | 50% coverage for most services | 55% coverage for most services | 60% coverage for most services | 70% coverage for most services |
| Out of Pocket Mzx | $8200/16,400 family | $8200/16,400 family | $8200/$16,400 family | $8200/$16,400 family |
| Ambulance | 50% coverage (after ded) | 55% coverage (ded applies) | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Chiropractor | Not covered | Not covered | Not covered | Not covered |
| Durable Med Equip | 50% coverage (after ded) | 55% coverage | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Emergency Room | 50% coverage (after ded) | 55% coverage (ded applies) | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Hospital | 50% coverage (after ded) | 55% coverage (ded applies) | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Infertility | Optional | Optional | Not covered | Not covered |
| Lab & X-Ray | 50% coverage (after ded) | $30 lab/$75 X-ray | $40 lab/X-ray 60% after ded | $50 lab/$85 X-ray |
| Office Visit | $60 copay first 3 visits then deductible applies | $55 copayment | $65 copayment | $50 copayment |
| Specialist | $80 copay first 3 visits then deductible applies | $80 copayment | $95 copayment | $85 copayment |
| Outpatient Surgery | 50% coverage (after ded) | 55% coverage (ded applies) | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Physical Therapy | $65 copayment | $65 copayment | $65 copayment | $50 copayment (after deductible) |
| Inpatient Psych | 50% coverage (after ded) | 55% coverage (ded applies) | 60% coverage (after deductible) | 70% coverage (after deductible) |
| Outpatient Psych | $60 copay first 3 visits then deductible applies | $55 copayment | $65 copayment | $50 copayment |
| Rx Tier 1 | $20 copay | $20 copay | $18 copay after ded (after $500 Rx ded) | $17 copayment |
| Rx Tier 2 | 50% coverage to $500 (med ded applies) | $75 copay (after med ded) | 60% coverage up to $500 per Rx (after $500 Rx ded) | $70 copayment (after $300 Rx ded) |
| Rx Tier 3 | 50% coverage to $500 (med ded applies) | $75 copay (after med ded) | 60% coverage up to $500 per Rx (after $500 Rx ded) | $100 copayment (after $300 Rxded) |
| Rx Tier 4 | 50% coverage to $500 (med ded applies) | 55% coverage to $250 (plan ded applies) | 60% coverage up to $500 per Rx (after $500 Rx ded) | 70% coverage up to $250 per Rx (after $300 Rxded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Bee Vang | 325.98 | 377.49 | 509.31 | 610.02 |
| Daron Bracht | 455.09 fam 1035.14 | 527 fam 1196.5 | 711.03 fam 1595.44 | 851.64 fam 1910.94 |
| Total | 781.07 w deps 1361.12 | 904.49 w deps 1573.99 | 1220.34 w deps 2104.75 | 1461.66 w deps 2520.96 |