|  |  | |
| Plan | Bronze Trio HMO 7000/70 Offex | Bronze 60 HMO HSA (shop) | Bronze 60 HMO 5800/60 (shop) |
| Metal | Bronze | Bronze | Bronze |
| Network | Trio ACO Network | Kaiser Permanente | Kaiser Permanente |
| Deductible | $7000/$14,000 family | $6650/$13,300 family | $5800/$11,600 family |
| Coinsurance | 50% coverage for most services | 100% coverage for most services | 60% coverage for most services |
| Out of Pocket Mzx | $8850/$17,700 family | $6650/$13,300 family | $8850/19,700 family |
| Ambulance | 50% coverage (after deductible | 100% coverage (after deductible) | 60% coverage (after ded) |
| Chiropractor | $15 copayment (20 visits max) | Full coverage if physician referral (ded applies) | $60 copay (physciain referral) |
| Durable Med Equip | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after ded) |
| Emergency Room | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after ded) |
| Hospital | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after ded) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | Lab: $65 copay/X-ray: $115 | 100% coverage (after deductible) | Lab $40/X-ray 60% coverage (after ded) |
| Office Visit | $70 copayment | 100% coverage (after deductible) | $60 copay (ded waived) |
| Specialist | $80 copayment | 100% coverage (after deductible) | $95 copayment (ded applies) |
| Outpatient Surgery | 50% coverage (after deductible) | 100% coverage (after deductible) | 60% coverage (after ded) |
| Physical Therapy | $70 copayment | 100% coverage (after deductible) | $60 copayment |
| Inpatient Psych | $70 copayment | 100% coverage (after deductible) | 60% coverage (after ded) |
| Outpatient Psych | 50% coverage (after deductible) | 100% coverage (after deductible) | $60 copay (ded applies) |
| Rx Tier 1 | $25 copayment | 100% coverage (after deductible) | $19 copay |
| Rx Tier 2 | $115 copayment (after medical ded) | 100% coverage (after deductible) | 60% coverage to $500 ($450 Rx ded applies) |
| Rx Tier 3 | $160 copayment (after medical ded) | 100% coverage (after deductible) | 60% coverage to $500 ($450 Rx ded applies) |
| Rx Tier 4 | 50% cov to $500 after medical ded | 100% coverage (after deductible) | 60% coverage to $500 ($450 Rx ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Freddy Fender | 367.19 | 367.45 | 383.52 |
| Ringo Starr | 342.97 | 343.22 | 358.23 |
| Total | 710.16 | 710.67 | 741.75 |