|  | | | |
| Plan | Silver 70 HMO 2950/65 (shop) | Silver 70 HMO 2300/65 (shop) | Silver 70 HMO 2500/55 (shop) | Silver 70 HMO 1900/65 (shop) |
| Metal | Silver | Silver | Silver | Silver |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $2950/$5900 family | $2300/$4600 family | $2500/$5000 family | $1900/$3800 family |
| Coinsurance | 55% coverage for most services | 55% coverage for most services | Fixed copays for most services | 55% coverage for most services |
| Out of Pocket Mzx | $9100/18,200 family | $8750/17,500 family | $8750/17,500 family | $8750/17,500 family |
| Ambulance | 55% coverage (after ded) | 55% coverage (after ded) | 65% coverage (ded applies) | 55% coverage (after ded) |
| Chiropractor | $15 copay (20 visits ann max) | $15 copay (20 visits ann max) | $65 copay (physciain referral) | $15 copay (20 visits ann max) |
| Durable Med Equip | 65% coverage | 55% coverage (ded applies) | 65% coverage (ded applies) | 55% coverage (after ded) |
| Emergency Room | 55% coverage (ded applies) | 55% coverage (ded applies) | 65% coverage (ded applies) | 55% coverage (after ded) |
| Hospital | 55% coverage (ded applies) | 55% coverage (ded applies) | 65% coverage (ded applies) | 55% coverage (after ded) |
| Infertility | Optional | Optional | Optional | Optional |
| Lab & X-Ray | $30 lab after ded/$75 X-ray after ded | $30 lab/$75 X-ray after ded | $55 lab/$90 X-ray | $30 lab/$75 X-ray after ded |
| Office Visit | $65 copayment | $65 copayment | $55 copayment | $65 copayment |
| Specialist | $100 copayment | $100 copayment | $90 copayment | $100 copayment |
| Outpatient Surgery | 55% coverage (ded applies) | 65% coverage (after ded) | 65% coverage (after ded) | 55% coverage (after ded) |
| Physical Therapy | $65 copayment | $55 copayment | $55 copayment | $65 copayment |
| Inpatient Psych | 55% coverage (ded applies) | 55% coverage (ded applies) | 65% coverage (ded applies) | 55% coverage (after ded) |
| Outpatient Psych | $65 copayment | $65 copayment | $55 copayment | $65 copayment |
| Rx Tier 1 | $20 copay | $20 copay | $19 copay | $20 copay |
| Rx Tier 2 | $100 copay (after med ded) | $100 copay (after $500 Rx ded) | $85 copay (after $300 Rx ded) | $100 copayment |
| Rx Tier 3 | $100 copay (after med ded) | $100 copay (after $500 Rx ded) | $85 copay (after $300 Rx ded) | $100 copayment |
| Rx Tier 4 | 55% coverage to $250 (med ded applies) | 80% cov $250 max (after $370 Rx ded) | 70% cov $250 max (after $300 Rx ded) | 80% cov $250 max ben (after medical ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Adrian Razo | 451.96 | 468.02 | 474.28 | 477.38 |
| Adrian T Garcia | 685.29 | 709.63 | 719.13 | 723.83 |
| Alejandro Huerta | 656.27 | 679.57 | 688.66 | 693.16 |
| Alejandro Laureles | 486.87 | 504.16 | 510.91 | 514.25 |
| Amy Cooper | 600.78 | 622.12 | 630.44 | 634.56 |
| Andres Figueroa | 513.33 | 531.56 | 538.67 | 542.19 |
| Daniel Calva | 486.87 | 504.16 | 510.91 | 514.25 |
| Gabriel Montiel Lope | 356.43 | 369.09 | 374.02 | 376.47 |
| Humberto Calva G | 449.02 | 464.97 | 471.19 | 474.27 |
| Jesus Vazquez | 376.27 | 389.63 | 394.84 | 397.42 |
| Jose Alaya | 685.29 | 709.63 | 719.13 | 723.83 |
| Juan Alvarado | 454.9 | 471.06 | 477.36 | 480.48 |
| Martin Bayol | 367.45 | 380.5 | 385.59 | 388.11 |
| Maurilio C Vargas | 463.72 | 480.19 | 486.61 | 489.79 |
| Mike Graveman | 626.87 | 649.13 | 657.82 | 662.12 |
| Spencer Temple | 434.69 | 450.13 | 456.15 | 459.13 |
| Total | 8096.01 | 8383.55 | 8495.71 | 8551.24 |