|  |  | |
| Plan | Platinum Trio HMO 0/30 OffEx | Silver PPO 55/2500/45% 4J00 | Silver PPO 2000/30% w/HSA 4HW2 |
| Metal | Platinum | Silver | Silver |
| Network | Trio ACO Network | Prudent Buyer PPO | Prudent Buyer PPO |
| Deductible | None | $2500/$5000 family | $2000 or $2800($4000 family) |
| Coinsurance | Fixed copays for most services | 55% coverage for most services | 70% coverage for most services |
| Out of Pocket Mzx | $2950/$5900 family | $8150/$16,300 family | $6500/$13,000 family |
| Ambulance | $150 copayment | 55% coverage (ded applies) | 70% coverage (ded applies) |
| Chiropractor | $15 copayment (15 visits max) | Limited coverage | Limited coverage |
| Durable Med Equip | 50% coverage | 50% coverage (ded applies) | 50% coverage (ded applies) |
| Emergency Room | $250 copayment | $350 copay then 55% coverage (ded apples) | 70% coverage (ded applies) |
| Hospital | $500 per day 1st 4 days | 55% coverage (ded applies) | 70% coverage (ded applies) |
| Infertility | Not covered | Not covered | Not covered |
| Lab & X-Ray | Lab $30 copay / X-ray $50 copay | $55 lab/$85 X-ray copayment | 70% coverage (ded applies) |
| Office Visit | $30 copayment | $55 copayment | 70% coverage (ded applies) |
| Specialist | $50 copayment | $85 copayment | 70% coverage (ded applies) |
| Outpatient Surgery | $100 or$150 copay | 55% coverage (ded applies) | 70% coverage (ded applies) |
| Physical Therapy | $30 copayment | | 70% coverage (ded applies) |
| Inpatient Psych | $500 per day 1st 4 days | 55% coverage (ded applies) | 70% coverage (ded applies) |
| Outpatient Psych | $30 copayment | $55 copayment | 70% coverage (ded applies) |
| Rx Tier 1 | $5 copayment | $20 copayment | $20 copayment (after ded) |
| Rx Tier 2 | $15 copayment | $60 copayment | $55 copayment (after ded) |
| Rx Tier 3 | $25 copayment | $100 copayment | $80 copayment (after ded) |
| Rx Tier 4 | 80% coverage up to $250 per Rx | 70% coverage to $250 max $150 Rx ded | 70% coverage to $250 max (ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Daffy Duck | 968.28 | 1024.38 | 1030.14 |
| Leon Spinks | 504.47 fam 942.46 | 533.7 fam 997.06 | 536.7 fam 1002.67 |
| Terry Bradshaw | 394.41 | 417.26 | 419.61 |
| Total | 1867.16 w deps 2305.15 | 1975.34 w deps 2438.70 | 1986.45 w deps 2452.42 |