|  | |
| Plan | Bronze Select PPO 70/6600/35% | Silver Select HMO 55 |
| Metal | Bronze | Silver |
| Network | Select PPO | Select HMO |
| Deductible | $6600/$13,200 family | None |
| Coinsurance | 65% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8900/$17,800 family | $9200/$18,400 family |
| Ambulance | 65% coverage (ded applies) | $150 copayment |
| Chiropractor | 50% cov (20 visits max) | $15 copay (30 visits max) |
| Durable Med Equip | 50% coverage (ded applies) | 50% coverage (ded applies) |
| Emergency Room | $250 copay then 65% cov (ded apples) | $500 copayment |
| Hospital | 65% coverage (ded applies) | $750 daily 1st 5 days |
| Infertility | Optional | Optional |
| Lab & X-Ray | 65% coverage (ded applies) | $40 lab/$40 X-ray copayment |
| Office Visit | $70 copay (ded applies) | $55 copayment |
| Specialist | 65% coverage (ded applies) | $110 copayment |
| Outpatient Surgery | $200 copay then 65% cov (ded applies) | $600 copayment |
| Physical Therapy | 65% coverage (ded applies) | $55 copayment |
| Inpatient Psych | 65% coverage (ded applies) | $750 daily 1st 5 days |
| Outpatient Psych | $70 copayment | $55 copayment |
| Rx Tier 1 | $20 copayment | $20 copayment |
| Rx Tier 2 | $80 copay (med ded applies) | $95 copay (after $400 Rx ded) |
| Rx Tier 3 | $120 copayment (med ded applies) | $150 copay (after $400 Rx ded) |
| Rx Tier 4 | 70% coverage to $400 max (med ded applies) | 70% coverage to $250 max ($400 Rx ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Amy Ellis | 402.23 fam 829.97 | 422.29 fam 871.36 |
| Brian Ricardo Jarret | 968.46 fam 1299.03 | 1016.76 fam 1363.81 |
| Claudio Alvarez | 504.57 | 529.73 |
| Dalila Prudencio | 350.91 | 368.41 |
| Damon Thomas | 602.06 fam 1178.62 | 632.09 fam 1237.4 |
| Donovan Adams | 689.22 fam 1594.73 | 723.59 fam 1674.26 |
| Francisco Hernandez | 407.4 fam 814.8 | 427.72 fam 855.44 |
| Francisco Valencia | 407.4 fam 789.3 | 427.72 fam 828.66 |
| Helen Chavez | 394.49 | 414.16 |
| Jacqueline Ramirez | 374.15 | 392.81 |
| Jesse Mateos | 361.24 | 379.25 |
| Joshua Monjaraz | 394.49 | 414.16 |
| Kay Wong | 402.23 | 422.29 |
| Margarita Beltran | 719.89 | 755.79 |
| Mario Angel | 504.57 | 529.73 |
| MariselaTirado | 504.57 | 529.73 |
| Michael Ellis | 968.46 fam 1936.92 | 1016.76 fam 2033.52 |
| Michele Awaa | 753.14 fam 1944.35 | 790.7 fam 2041.32 |
| Mixie De La Cruz | 322.82 | 338.92 |
| Norma Flores | 576.56 | 605.31 |
| Ramon Angel | 322.82 | 338.92 |
| Roger Maldonado | 407.4 | 427.72 |
| Rosemary Mendoza | 338.32 | 355.19 |
| Ruth De La Cruz | 658.55 | 691.4 |
| Ryan Meller | 550.73 fam 1572.45 | 578.2 fam 1650.88 |
| Sabrina Young | 361.24 | 379.25 |
| Total | 13247.92 w deps 19458.99 | 13908.60 w deps 20429.42 |