|  | | | | |
| Plan | Silver Full PPO 1800/55 OffEx | Gold Full PPO 0/20 OffEx | Silver Full PPO 2300/45 OffEx | Silver AccessPlus HMO 2350/65 OffEx | Gold AccessPlus HMO 0/30 OffEx |
| Metal | Silver | Gold | Silver | Silver | Gold |
| Network | Full PPO Network | Full PPO Network | Full PPO Network | AccessPlus HMO | AccessPlus HMO |
| Deductible | $1800/$3600 family | None | $4000/$10,000 family | $2350/$4700 family | None |
| Coinsurance | 65% coverage for most services | 70% coverage for most services | 70% coverage for most services | 55% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7800/$15,600 family | $7650/$15,300 family | $7800/$15,600 family | $7800/$15,600 family | $7500/15,000 family |
| Ambulance | 65% coverage (after deductible) | 70% coverage | 70% coverage after ded | $175 copayment (after ded) | $175 copayment |
| Chiropractor | $15 per visit | Not covered | $15 per visit | $15 copayment (15 visits max) | $15 copayment (15 visits max) |
| Durable Med Equip | 50% coverage (after deductible) | 50% coverage | 50% coverage (after deductible) | 50% coverage (after deductible) | 50% coverage |
| Emergency Room | $350 per visit then 65% cov after ded | $250 copay then 70% coverage | 50% coverage (after deductible) | 50% coverage (after deductible) | $325 copayment |
| Hospital | 65% coverage (after deductible) | 70% coverage | 70% coverage after ded | 55% coverage (after deductible) | $600 per day 1st 5 days |
| Infertility | Not covered | Not covered | Not covered | Not covered | |
| Lab & X-Ray | Lab: $55 copay/X-ray: $80 | $20 lab/$50 X-ray | 70% coverage after ded | Lab: $55 copay/X-ray: $100 | Lab $30 copay / X-ray $55 copay |
| Office Visit | $55 copayment | $20 copayment | $70 copayment (after ded) | $65 copayment | $30 copayment |
| Specialist | $80 copayment | $50 copayment | $95 copayment (after ded) | $95 copayment | $55 copayment |
| Outpatient Surgery | 65% coverage (after deductible) | $150 copayment (then 70% coverage) | 70% coverage after ded | $250 or $1000 copay after ded | $150 or$300 copay |
| Physical Therapy | 65% coverage (after deductible) | 70% coverage | $70 copayment (after ded) | $65 copayment | $30 copayment |
| Inpatient Psych | 65% coverage (after deductible) | 70% coverage | 70% coverage after ded | 55% coverage (after deductible) | $600 per day 1st 5 days |
| Outpatient Psych | $55 copayment | $20 copayment | $70 copayment (after ded) | $65 copayment | $30 copayment |
| Rx Tier 1 | $20 copayment | $15 copayment | $20 copayment (after med ded) | $20 copayment (after $350 Rx ded) | $15 copayment |
| Rx Tier 2 | $75 copayment (after $300 Rx ded) | $40 copayment | $65 copayment (after med ded) | $85 copayment (after $350 Rx ded) | $35 copayment |
| Rx Tier 3 | $115 copayment (after $300 Rx ded) | $60 copayment | $90 copayment (after med ded) | $115 copayment (after $350 Rx ded) | $55 copayment |
| Rx Tier 4 | 70% coverage up to $250 per Rx (after $300 Rx ded) | 70% coverage up to $250 per Rx | 70% coverage up to $500 per Rx (after med ded) | 55% cov max $250 ben after $35 Rx ded) | 80% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| John Doe | 787.54 fam 2081.48 | 844.42 fam 2231.81 | 954.65 fam 2523.14 | 1012.99 fam 2677.33 | 1253.91 fam 3314.09 |
| Mary Jane | 394.9 | 423.42 | 478.69 | 507.95 | 628.76 |
| Total | 1182.44 w deps 2476.38 | 1267.84 w deps 2655.23 | 1433.34 w deps 3001.83 | 1520.94 w deps 3185.28 | 1882.67 w deps 3942.85 |