|  | | | |
| Plan | Silver 70 HMO 1650/55 (shop) | Silver 70 HMO 2250/50 (shop) | Gold 80 HRA | Gold 80 HMO 250/25 (shop) |
| Metal | Silver | Silver | Gold | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $1650/$3300 family | $2250/$4500 family | $2250/$4500 family | $250 ($500 family) |
| Coinsurance | 60% coverage for most services | 80% coverage for most services | 75% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $7800/15,600 family | $7800/15,600 family | $7800/15,600 family | $7800/15,600 family |
| Ambulance | 60% coverage (after ded) | $250 (after deductible) | 75% coverage (after deductible) | $250 copayment (after ded) |
| Chiropractor | Not covered | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | 80% coverage (ded applies) | 50% coverage (ded applies) | 80% coverage (after ded) |
| Emergency Room | 60% coverage (after ded) | $250 copay after ded | 75% coverage after ded | $250 copayment (after ded) |
| Hospital | 60% coverage (after ded) | 80% coverage (after deductible) | 75% coverage after ded | $600 per day per admit ($3000 max) |
| Infertility | Optional | Optional | Optional | Optional |
| Lab & X-Ray | $25 lab/$75 X-ray after ded | $40 lab/$85 X-ray | 75% coverage after ded | $25 lab/$65 X-ray |
| Office Visit | $55 copayment | $50 copayment | $35 copayment | $25 copayment |
| Specialist | $80 copayment | $85 copayment | $50 copayment | $50 copayment |
| Outpatient Surgery | 60% coverage (after ded) | 80% coverage (after deductible) | 75% coverage (after deductible) | $34 copayment (per procedure) |
| Physical Therapy | $65 copayment | $50 copayment | $35 copayment (ded applies) | $25 copayment |
| Inpatient Psych | 60% coverage (after ded) | 80% coverage (after deductible) | 75% coverage after ded | $600 per day per admit ($3000 max) |
| Outpatient Psych | $55 copayment | $50 copayment | $35 copayment | $25 copayment |
| Rx Tier 1 | $20 copay | $500 Rx ded then $17 ded per Rx | $15 copayment | $15 copayment |
| Rx Tier 2 | $75 copay (after $350 Rx ded) | $65 copay (after $300 Rx ded) | $30 copayment (aftr $100 Rx ded) | $50 copayment |
| Rx Tier 3 | $75 copay (after $350 Rx ded) | $65 copay (after $300 Rx ded) | $30 copayment (aftr $100 Rx ded) | $50 copayment |
| Rx Tier 4 | 80% cov $250 max ben (after $350 Rx ded) | 80% cov $250 max ben (after $300 Rx ded) | 80% cov up to $250 per Rx after $100 Rx ded | 80% coverage to $250 max ben (ded waived) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Bugs Bunny | 351.2 | 362.91 | 378.75 | 425.49 |
| Roger Rabbit | 449.21 fam 839.21 | 464.18 fam 867.18 | 484.44 fam 905.03 | 544.22 fam 1016.71 |
| Total | 800.41 w deps 1190.41 | 827.09 w deps 1230.09 | 863.19 w deps 1283.78 | 969.71 w deps 1442.20 |