|  | | |  | | |
| Plan | Bronze 60 HMO 5800/60 (shop) | Silver 70 HMO 1900/65 (shop) | Gold 80 HMO 250/35 (shop) | Bronze 60 PPO 5800/60 w Child Dental (shop) | Silver 70 PPO 2500/55 w Child Dental (shop) | Gold 80 PPO 350/25 w Child Dental (shop) |
| Metal | Bronze | Silver | Gold | Bronze | Silver | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $5800/$11,600 family | $1900/$3800 family | $250 ($500 family) | $5800/$11,600 family | $2500/$5000 family | $350/$700 family |
| Coinsurance | 60% coverage for most services | 55% coverage for most services | Fixed copays for most services | 60% coverage for most services | 65% coverage for most services | 80% coverage for most services |
| Out of Pocket Mzx | $8850/19,700 family | $8750/17,500 family | $7800/15,600 family | $8850/$17,700 family | $8600/$17,200 family | $7800/$15,600 family |
| Ambulance | 60% coverage (after ded) | 55% coverage (after ded) | $250 copay (after ded) | 60% coverage (after deductible) | 65% coverage (after deductible) | 80% cov (ded applies) |
| Chiropractor | $60 copay (physciain referral) | $15 copay (20 visits ann max) | $35 copay (accupuncture only) | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | 55% coverage (after ded) | 80% coverage | 60% coverage (after deductible) | 65% coverage (after deductible) | 80% coverage |
| Emergency Room | 60% coverage (after ded) | 55% coverage (after ded) | $250 copay (after ded) | 60% coverage (after deductible) | 65% coverage (after deductible) | 80% cov (ded applies) |
| Hospital | 60% coverage (after ded) | 55% coverage (after ded) | $600 per day 1st 5 days | 60% coverage (after deductible) | 65% coverage (after deductible) | 80% coverage (after deductible) |
| Infertility | Optional | Optional | Optional | Not covered | Not covered | Not covered |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) | $30 lab/$75 X-ray after ded | $35 lab/$55 X-ray | $40 lab/X-ray 60% after ded | $55 lab/$90 X-ray | $25 lab/$65 X-ray |
| Office Visit | $60 copay (ded waived) | $65 copayment | $35 copayment | $60 copay 1st 3 visits (then ded applies) | $55 copayment | $25 copayment |
| Specialist | $95 copayment (ded applies) | $100 copayment | $55 copayment | $95 copay 1st 3 visits (then ded applies) | $90 copayment | $50 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 55% coverage (after ded) | $335 copay (after ded) | 60% coverage (after deductible) | 65% coverage (after deductible) | 80% coverage |
| Physical Therapy | $60 copayment | $65 copayment | $35 copayment | $60 copayment | $55 copayment (after deductible) | $25 copayment |
| Inpatient Psych | 60% coverage (after ded) | 55% coverage (after ded) | $600 per day 1st 5 days | $60 copay 1st 3 visits (then ded applies) | $55 copayment | $25 copayment |
| Outpatient Psych | $60 copay (ded applies) | $65 copayment | $35 copayment | 60% coverage (after deductible) | 60% coverage (after deductible) | 80% coverage (after deductible) |
| Rx Tier 1 | $19 copay | $20 copay | $15 copayment | $19 copay after ded (after $500 Rx ded) | $20 copayment | $15 copayment |
| Rx Tier 2 | 60% coverage to $500 ($450 Rx ded applies) | $100 copayment | $40 copayment | 60% coverage up to $500 per Rx (after $450 Rx ded) | $75 copayment (after $300 Rx ded) | $50 copayment |
| Rx Tier 3 | 60% coverage to $500 ($450 Rx ded applies) | $100 copayment | $40 copayment | 60% coverage up to $500 per Rx (after $450 Rx ded) | $105 copayment (after $300 Rxded) | $80 copayment |
| Rx Tier 4 | 60% coverage to $500 ($450 Rx ded applies) | 80% cov $250 max ben (after medical ded) | 80% coverage to $250 | 60% coverage up to $500 per Rx (after $500 Rx 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 | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Adam Smith | 697.51 | 780.68 | 941.66 | 989.92 | 1186.05 | 1327.95 |
| Adrian Larimer | 388.42 | 434.73 | 524.38 | 551.25 | 660.47 | 739.49 |
| Adriana Miller | 456.67 | 511.12 | 616.52 | 648.11 | 776.53 | 869.42 |
| Alejandro La O Garci | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Aleksei Dubik | 473.46 | 529.92 | 639.19 | 671.95 | 805.08 | 901.4 |
| Alekxander Ortege | 414.15 | 463.53 | 559.11 | 587.76 | 704.22 | 788.47 |
| Alexander Smith | 399.85 | 447.53 | 539.82 | 567.48 | 679.92 | 761.26 |
| Andrea Leon Reyes | 388.42 | 434.73 | 524.38 | 551.25 | 660.47 | 739.49 |
| Angelina Zhuravskaya | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Anthony Nguyen | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Bryan Leon Guzman | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Caitlin Laidig | 433.8 | 485.53 | 585.65 | 615.66 | 737.64 | 825.88 |
| Christopher Marinell | 796.85 | 891.87 | 1075.77 | 1130.9 | 1354.97 | 1517.07 |
| Colby Benton | 456.67 | 511.12 | 616.52 | 648.11 | 776.53 | 869.42 |
| Conner Wallace | 388.42 | 434.73 | 524.38 | 551.25 | 660.47 | 739.49 |
| Denis Morales Viilla | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Derek Mercure | 499.19 | 558.72 | 673.93 | 708.46 | 848.83 | 950.38 |
| Derron Muillo | 405.57 | 453.93 | 547.54 | 575.59 | 689.64 | 772.14 |
| Emilia Hernandez | 388.42 | 434.73 | 524.38 | 551.25 | 660.47 | 739.49 |
| Eric Mellett | 358.76 | 401.54 | 484.34 | 509.16 | 610.04 | 683.02 |
| Gordon Jensen | 399.85 | 447.53 | 539.82 | 567.48 | 679.92 | 761.26 |
| Gringo Villapando | 442.37 | 495.13 | 597.22 | 627.83 | 752.22 | 842.21 |
| Ian Cwiok | 365.91 | 409.54 | 493.99 | 519.3 | 622.19 | 696.63 |
| Isaiah Grandon | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Jacob Ross | 399.85 | 447.53 | 539.82 | 567.48 | 679.92 | 761.26 |
| Jaylin Curl | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Jeffer Macias Arias | 365.91 | 409.54 | 493.99 | 519.3 | 622.19 | 696.63 |
| John Tuberville | 405.57 | 453.93 | 547.54 | 575.59 | 689.64 | 772.14 |
| Joseph Martin | 638.19 | 714.29 | 861.58 | 905.73 | 1085.19 | 1215.02 |
| Joshua Podesta | 374.48 | 419.14 | 505.57 | 531.47 | 636.78 | 712.95 |
| Juan Delgado Rincon | 436.66 | 488.73 | 589.51 | 619.71 | 742.5 | 831.33 |
| Juan Leon-Reyes | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Justin Croft | 436.66 | 488.73 | 589.51 | 619.71 | 742.5 | 831.33 |
| Justin Hartman | 433.8 | 485.53 | 585.65 | 615.66 | 737.64 | 825.88 |
| Liam Desomond | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Madison Smith | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Marina Kosykh | 445.23 | 498.33 | 601.08 | 631.88 | 757.08 | 847.65 |
| Matthew Mellett | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Michael Phelps | 442.37 | 495.13 | 597.22 | 627.83 | 752.22 | 842.21 |
| Myra Cabrera Garcia | 399.85 | 447.53 | 539.82 | 567.48 | 679.92 | 761.26 |
| Nicholas Blocker | 357.33 | 399.94 | 482.41 | 507.13 | 607.61 | 680.3 |
| Paul Kaser | 436.66 | 488.73 | 589.51 | 619.71 | 742.5 | 831.33 |
| Rafael Cabrera | 374.48 | 419.14 | 505.57 | 531.47 | 636.78 | 712.95 |
| Reggie Rodriguez | 388.42 | 434.73 | 524.38 | 551.25 | 660.47 | 739.49 |
| Rolf Buff | 473.46 | 529.92 | 639.19 | 671.95 | 805.08 | 901.4 |
| Ryan Keely | 374.48 | 419.14 | 505.57 | 531.47 | 636.78 | 712.95 |
| Salesi Fotu | 374.48 | 419.14 | 505.57 | 531.47 | 636.78 | 712.95 |
| Samet Uyer | 439.52 | 491.93 | 593.36 | 623.77 | 747.36 | 836.77 |
| Scott Fountain | 405.57 | 453.93 | 547.54 | 575.59 | 689.64 | 772.14 |
| Seth Escobar | 414.15 | 463.53 | 559.11 | 587.76 | 704.22 | 788.47 |
| Stephonzie Walker | 414.15 | 463.53 | 559.11 | 587.76 | 704.22 | 788.47 |
| Tristan Haile | 358.76 | 401.54 | 484.34 | 509.16 | 610.04 | 683.02 |
| Tyler James | 399.85 fam 1053.11 | 447.53 fam 1177.01 | 539.82 fam 1416.84 | 567.48 fam 1474.73 | 679.92 fam 1766.93 | 761.26 fam 1978.32 |
| Wameng Lee | 399.85 | 447.53 | 539.82 | 567.48 | 679.92 | 761.26 |
| Total | 22474.65 w deps 23127.91 | 25154.62 w deps 25884.10 | 30341.70 w deps 31218.72 | 31896.43 w deps 32803.68 | 38216.27 w deps 39303.28 | 42788.19 w deps 44005.25 |