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| Plan | Trio Silver 70 HMO 2250/55 w Child Dental (shop) | Trio Gold 80 HMO 250/35 w Child Dental (shop) | Bronze 60 PPO 6300/65 w Child Dental (shop) | Silver 70 PPO 2500/55 w Child Dental (shop) | Platinum 90 PPO 0/15 w Child Dental (shop) |
| Metal | Silver | Gold | Bronze | Silver | Platinum |
| Network | Trio ACO Network | Trio ACO Network | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $2500/$5000 family | $250/$500 family | $6300/$12,600 family | $2500/$5000 family | None |
| Coinsurance | 80% coverage for most services | Fixed copays for most services | 60% coverage for most services | 65% coverage for most services | 90% coverage for most services |
| Out of Pocket Mzx | $8750/$17,500 family | $7800/$15,600 family | $8200/$16,400 family | $8600/$17,200 family | $4500/9000 family |
| Ambulance | 70% coverage (after ded) | $250 copayment | 60% coverage (after deductible) | 65% coverage (after deductible) | $150 copayment |
| Chiropractor | Not covered | Not covered | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (ded waived) | 80% coverage | 60% coverage (after deductible) | 65% coverage (after deductible) | 90% coverage |
| Emergency Room | 70% coverage (after ded) | $250 copayment | 60% coverage (after deductible) | 65% coverage (after deductible) | $200 copayment |
| Hospital | 60% coverage (after ded) | $600 per day 1st 5 days | 60% coverage (after deductible) | 65% coverage (after deductible) | 90% coverage |
| Infertility | Not covered | Not covered | Not covered | Not covered | Not covered |
| Lab & X-Ray | $55 lab/$90 X-ray | $35 lab/$55 X-ray | $40 lab/X-ray 60% after ded | $55 lab/$90 X-ray | Lab $15 copay / X-ray $30 copay |
| Office Visit | $55 copayment | $35 copayment | $65 copayment | $55 copayment | $15 copayment |
| Specialist | $90 copayment | $55 copayment | $95 copayment | $90 copayment | $30 copayment |
| Outpatient Surgery | 70% coverage (after ded) | $300 copayment | 60% coverage (after deductible) | 65% coverage (after deductible) | 90% coverage |
| Physical Therapy | $55 copayment | $35 copayment | $65 copayment | $55 copayment (after deductible) | $15 copayment |
| Inpatient Psych | 70% coverage (after ded) | $600 per day 1st 5 days | 60% coverage (after deductible) | 60% coverage (after deductible) | 90% coverage |
| Outpatient Psych | $55 copayment | $25 copayment | $65 copayment | $55 copayment | $15 copayment |
| Rx Tier 1 | $19 copayment | $15 copayment | $18 copay after ded (after $500 Rx ded) | $25 copayment | $10 copayment |
| Rx Tier 2 | $85 copayment (after $300 Rx ded) | $40 copayment | 60% coverage up to $500 per Rx (after $500 Rx ded) | $75 copayment (after $300 Rx ded) | $25 copayment |
| Rx Tier 3 | $110 copayment (after $300 Rxded) | $70 copayment | 60% coverage up to $500 per Rx (after $500 Rx ded) | $105 copayment (after $300 Rxded) | $40 copayment |
| Rx Tier 4 | 70% coverage up to $250 per Rx (after $300 Rxded) | 80% coverage up to $250 per Rx | 60% coverage up to $500 per Rx (after $500 Rx ded) | 70% coverage up to $250 per Rx (after $300 Rxded) | 90% coverage (up to $250 per Rx) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Charles Smyth | 401.86 fam 1297.18 | 489.07 fam 1578.68 | 559.62 fam 1806.41 | 641.59 fam 2071.01 | 818.98 fam 2643.61 |
| Total | 401.86 w deps 1297.18 | 489.07 w deps 1578.68 | 559.62 w deps 1806.41 | 641.59 w deps 2071.01 | 818.98 w deps 2643.61 |