|  |
| Plan | Bronze 60 HMO 5400/60 (shop) |
| Metal | Bronze |
| Network | Kaiser Permanente |
| Deductible | $5400/$10,800 family |
| Coinsurance | 50% coverage for most services |
| Out of Pocket Mzx | $8300/16,600 family |
| Ambulance | 50% coverage (after ded) |
| Chiropractor | $15 copay (20 visits ann max) |
| Durable Med Equip | 50% coverage (after ded) |
| Emergency Room | 50% coverage (after ded) |
| Hospital | 50% coverage (after ded) |
| Infertility | Optional |
| Lab & X-Ray | 50% coverage (after ded) |
| Office Visit | $60 copay first 3 visits then deductible applies |
| Specialist | $80 copay first 3 visits then deductible applies |
| Outpatient Surgery | 50% coverage (after ded) |
| Physical Therapy | $65 copayment |
| Inpatient Psych | 50% coverage (after ded) |
| Outpatient Psych | $60 copay first 3 visits then deductible applies |
| Rx Tier 1 | $20 copay |
| Rx Tier 2 | 50% coverage to $500 (med ded applies) |
| Rx Tier 3 | 50% coverage to $500 (med ded applies) |
| Rx Tier 4 | 50% coverage to $500 (med ded applies) |
| Links | Brochure Formulary Providers |
| Alejandro D | 469.38 |
| Edger C | 300.31 |
| Francisco O | 366.98 |
| Gary H | 765.19 |
| Gary L | 900.93 |
| Jorge A | 391 fam 1550.12 |
| Tina O | 355.27 |
| Will L | 669.69 |
| William O | 886.52 |
| Total | 5105.27 w deps 6264.39 |