|  |  |
| Plan | Silver 70 HMO 1650/55 (shop) | Trio Silver 70 HMO 2250/55 w Child Dental (shop) |
| Metal | Silver | Silver |
| Network | Kaiser Permanente | Trio ACO Network |
| Deductible | $1650/$3300 family | $2250/$4500 family |
| Coinsurance | 60% coverage for most services | 80% coverage for most services |
| Out of Pocket Mzx | $8200/16,400 family | $8200/$16,400 family |
| Ambulance | 60% coverage (after ded) | 70% coverage (after ded) |
| Chiropractor | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | 70% coverage (ded waived) |
| Emergency Room | 60% coverage (after ded) | 70% coverage (after ded) |
| Hospital | 60% coverage (after ded) | 70% coverage (after ded) |
| Infertility | Optional | Not covered |
| Lab & X-Ray | $30 lab/$75 X-ray after ded | $55 lab/$90 X-ray |
| Office Visit | $55 copayment | $55 copayment |
| Specialist | $80 copayment | $90 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 70% coverage (after ded) |
| Physical Therapy | $65 copayment | $55 copayment |
| Inpatient Psych | 60% coverage (after ded) | 70% coverage (after ded) |
| Outpatient Psych | $55 copayment | $55 copayment |
| Rx Tier 1 | $20 copay | $17 copayment (after $300 Rxd ed) |
| Rx Tier 2 | $75 copay (after $350 Rx ded) | $80 copayment (after $300 Rx ded) |
| Rx Tier 3 | $75 copay (after $350 Rx ded) | $110 copayment (after $300 Rxded) |
| Rx Tier 4 | 80% cov $250 max ben (after $350 Rx ded) | 70% coverage up to $250 per Rx (after $300 Rxded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Ismael | 531.85 fam 901.05 | 633.55 fam 1073.35 |
| Nate | 431.01 fam 1356.79 | 513.42 fam 1582.89 |
| Total | 962.86 w deps 2257.84 | 1146.97 w deps 2656.24 |