|  |
| Plan | Silver 70 HMO 1650/55 (shop) |
| Metal | Silver |
| Network | Kaiser Permanente |
| Deductible | $1650/$3300 family |
| Coinsurance | 60% coverage for most services |
| Out of Pocket Mzx | $8200/16,400 family |
| Ambulance | 60% coverage (after ded) |
| Chiropractor | Not covered |
| Durable Med Equip | 60% coverage (after ded) |
| Emergency Room | 60% coverage (after ded) |
| Hospital | 60% coverage (after ded) |
| Infertility | Optional |
| Lab & X-Ray | $30 lab/$75 X-ray after ded |
| Office Visit | $55 copayment |
| Specialist | $80 copayment |
| Outpatient Surgery | 60% coverage (after ded) |
| Physical Therapy | $65 copayment |
| Inpatient Psych | 60% coverage (after ded) |
| Outpatient Psych | $55 copayment |
| Rx Tier 1 | $20 copay |
| Rx Tier 2 | $75 copay (after $350 Rx ded) |
| Rx Tier 3 | $75 copay (after $350 Rx ded) |
| Rx Tier 4 | 80% cov $250 max ben (after $350 Rx ded) |
| Links | Brochure Formulary Providers |
| Jorge A | 410.52 |
| Tina O | 384.82 |
| Will L | 725.4 |
| Total | 1520.74 |