|  |
| Plan | Link Silver Vivity HMO 50/2250 WH 6BW2 |
| Metal | Silver |
| Network | Vivity HMO Network |
| Deductible | $2250/$4500 family |
| Coinsurance | Fixed copays for most services |
| Out of Pocket Mzx | $8500/$17,000 family |
| Ambulance | $500 copayment |
| Chiropractor | 20 visits max (other limitations apply) |
| Durable Med Equip | 50% coverage (ded applies) |
| Emergency Room | $500 copayment |
| Hospital | $1500 copay per admission |
| Infertility | Optional |
| Lab & X-Ray | $25 lab/$350 X-ray copayment |
| Office Visit | $50 copayment |
| Specialist | $110 copayment |
| Outpatient Surgery | $1000 copay per admission |
| Physical Therapy | $30 copayment |
| Inpatient Psych | $1500 copay per admission |
| Outpatient Psych | $50 copayment |
| Rx Tier 1 | $20 copayment |
| Rx Tier 2 | $75 copayment |
| Rx Tier 3 | $150 copay (after $150 Rx ded) |
| Rx Tier 4 | 70% coverage to $250 max ($150 Rx ded applies) |
| Links | Brochure Formulary Providers |
| Cathy | 595.87 |
| Shari | 382.17 |
| Total | 978.04 |