|  | | |
| Plan | Gold Full PPO 500/30 OffEx | Gold Full PPO 0/25 OffEx | Gold 80 PPO 350/25 w Child Dental (shop) |
| Metal | Gold | Gold | Gold |
| Network | Full PPO Network | Full PPO Network | Full PPO Network |
| Deductible | $500/$1000 family | None | $350/$700 family |
| Coinsurance | 80% coverage for most services | Fixed copays for most services | 80% coverage for most services |
| Out of Pocket Mzx | $8150/$16,100 family | $8150/$16,300 family | $7800/$15,600 family |
| Ambulance | 80% coverage after ded | $150 copayment | 80% coverage |
| Chiropractor | $10 per visit after ded (20 visits max) | $10 per visit (20 visits max) | Not covered |
| Durable Med Equip | 50% after ded | 50% coverage | 80% coverage |
| Emergency Room | $250 copay after ded then 20% | $250 copay plus 20% | $250 copayment |
| Hospital | 80% coverage (after deductible) | 80% coverage (after deductible | 80% coverage (after deductible) |
| Infertility | Optional | Optional | Not covered |
| Lab & X-Ray | $30 lab/$50 X-ray | Lab $30 copay / X-ray $50 copay | $25 lab/$65 X-ray |
| Office Visit | $30 copayment | $30 copayment | $25 copayment |
| Specialist | $55 copayment | $55 copayment | $50 copayment |
| Outpatient Surgery | $150 copayment (then 80% coverage) | 80% coverage | 80% coverage |
| Physical Therapy | 80% coverage (after deductible) | 80% coverage | $25 copayment |
| Inpatient Psych | 80% coverage (after deductible) | 80% coverage (after deductible | 80% coverage (after deductible) |
| Outpatient Psych | $30 copayment | $30 copayment | $25 copayment |
| Rx Tier 1 | $15 copaymemt | $15 copayment | $15 copayment |
| Rx Tier 2 | $50 copayment (after $100 Rx ded) | $50 copayment | $50 copayment |
| Rx Tier 3 | $80 copayment (after $100 Rx ded) | $80 copayment | $80 copayment |
| Rx Tier 4 | 70% cov after $100 Rx ded up to $250 per Rx | 70% coverage up to $250 per Rx | 80% coverage up to $250 per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| JYOTISHNA J | 512.6 fam 1662.91 | 517.21 fam 1677.85 | 533.79 fam 1731.64 |
| HARPREET KAUR | 461.01 fam 1578.82 | 465.16 fam 1593.01 | 480.07 fam 1644.08 |
| STEPHANIE | 461.01 | 465.16 | 480.07 |
| Total | 1434.62 w deps 3702.74 | 1447.53 w deps 3736.02 | 1493.93 w deps 3855.79 |