|  | |
| Plan | Bronze HMO 6000/40 HSA (shop) | Bronze 60 HMO 6300/75 (shop) |
| Metal | Bronze | Bronze |
| Network | Kaiser Permanente | Kaiser Permanente |
| Deductible | $6000/$12,000 family | $6300/$12,600 family |
| Coinsurance | 60% coverage for most services | Most services covered after oop is met |
| Out of Pocket Mzx | $6550/13,300 family | $7550/15,100 family |
| Ambulance | 60% coverage (after deductible) | 100% coverage (after oop) |
| Chiropractor | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after deductible) | 100% coverage (after oop) |
| Emergency Room | 60% coverage (waived if admitted) | 100% coverage (after oop) |
| Hospital | 60% coverage (after deductible) | 100% coverage (after oop) |
| Infertility | Optional | Optional |
| Lab & X-Ray | 60% coverage (after deductible) | Lab $40/X-ray 100% coverage (after oop) |
| Office Visit | 60% coverage (after deductible) | $75 copayment first 3 visits then deductible applies |
| Specialist | 60% coverage (after deductible) | $105 copayment first 3 visits then deductible applies |
| Outpatient Surgery | 60% coverage for (after deductible) | 100% coverage (after oop) |
| Physical Therapy | 60% coverage (after deductible) | $75 copayment |
| Inpatient Psych | 60% coverage (after deductible) | 100% coverage (after oop) |
| Outpatient Psych | 60% coverage (after deductible) | $75 copayment first 3 visits then deductible applies |
| Rx Tier 1 | 60% coverage/$500 max (after deductible) | $500 Rx ded then $500 ded per Rx |
| Rx Tier 2 | 60% coverage/$500 max (after deductible) | $500 Rx ded then $500 ded per Rx |
| Rx Tier 3 | 60% coverage/$500 max (after deductible) | $500 Rx ded then $500 ded per Rx |
| Rx Tier 4 | 60% coverage/$500 max (after deductible) | $500 Rx ded then $500 ded per Rx |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Gabriela | 265.18 | 274.76 |
| Jason | 274.1 | 284.01 |
| Joanna | 277.76 | 287.8 |
| Nina | 686.4 | 711.21 |
| Patricia | 675.42 | 699.83 |
| Susan | 582.98 fam 811.78 | 604.05 fam 841.12 |
| Yessenia | 319.63 | 331.19 |
| Total | 3081.47 w deps 3310.27 | 3192.85 w deps 3429.92 |