|  | | |
| Plan | Bronze Full PPO 7500/65 OffEx | Bronze Full PPO Savings 7000 OffEx | Bronze Full PPO 6850/55 OffEx |
| Metal | Bronze | Bronze | Bronze |
| Network | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $7500/$15,000 family | $7000/$14,000 family | $6850/$13,800 family |
| Coinsurance | 50% coverage for most services | 100% coverage for most services | 65% coverage for most services |
| Out of Pocket Mzx | $8350/$16,700 family | $7000/$14,000 family | $8350/$16,700 family |
| Ambulance | 50% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Chiropractor | 50% coverage (after deductible) | 100% coverage (after deductible) | $15 per visit (20 visits max) |
| Durable Med Equip | 50% coverage (after deductible) | 100% coverage (after deductible) | 50% coverage (after deductible) |
| Emergency Room | 50% coverage (after deductible) | 100% coverage (after deductible) | 50% coverage (after deductible) |
| Hospital | 50% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 50% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Office Visit | $65 copay (after deductible) | 100% coverage (after deductible) | $65 copayment (after ded) |
| Specialist | 50% coverage (after deductible) | 100% coverage (after deductible) | $75 copayment (after ded) |
| Outpatient Surgery | 50% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Physical Therapy | 50% coverage (after deductible) | 100% coverage (after deductible) | $65 copayment after ded |
| Inpatient Psych | 50% coverage (after deductible) | 100% coverage (after deductible) | 65% coverage (after deductible) |
| Outpatient Psych | $65 copay (after deductible) | 100% coverage (after deductible) | $65 copayment (after ded) |
| Rx Tier 1 | $20 copay | 100% coverage (after deductible) | $20 copay |
| Rx Tier 2 | 50% coverage up to $250 per Rx after med ded | 100% coverage (after deductible) | $65 copay (after $650 Rx ded) |
| Rx Tier 3 | 50% coverage up to $250 per Rx after med ded | 100% coverage (after deductible) | $90 copay (after $650 Rx ded) |
| Rx Tier 4 | 50% coverage up to $500 per Rx after med ded | 100% coverage (after deductible) | 70% coverage up to $500 per Rx after $650 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Christina | 710.31 | 730.9 | 742.89 |
| Patricia | 476.46 | 490.27 | 498.31 |
| Total | 1186.77 | 1221.17 | 1241.20 |