|  | | |
| Plan | Bronze 60 EPO 6300/65 | Silver 2000 EPO | Silver 70 EPO 1500/50 (shop) |
| Metal | Bronze | Silver | Silver |
| Network | Oscar EPO | Oscar EPO | Oscar EPO |
| Deductible | $6300/$12,600 family | $2000/$4000 family | $1500/$3000 family |
| Coinsurance | 60% coverage for most services | Fixed copayments for most services | Fixed copayments for most services |
| Out of Pocket Mzx | $7800 ($15,600 fam) | $8150 ($16,300 fam) | $8150 ($16,300 fam) |
| Ambulance | 60% coverage (after ded) | Covered benefit | Covered benefit |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 60% coverage (after ded) | Covered benefit | Covered benefit |
| Emergency Room | 60% coverage (after ded) | Covered benefit | $750 copayment |
| Hospital | 60% coverage (after ded) | 50% coverage (after ded) | 50% coverage (after ded) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 60% coverage (after ded) | Lab: $75 copay/X-ray: $75 copay | Lab: $75 copay/X-ray: $75 copay |
| Office Visit | 3 @ $65 then ded applies | $50 copayment | $50 copayment |
| Specialist | 3 @ $95 then ded applies | $75 copayment | $75 copayment |
| Outpatient Surgery | 60% coverage (after ded) | Covered benefit | Covered benefit |
| Physical Therapy | 60% coverage (after ded) | Covered benefit | Covered benefit |
| Inpatient Psych | 60% coverage (after ded) | 50% coverage (after ded) | 50% coverage (after ded) |
| Outpatient Psych | $65 copayment | $50 copayment | $50 copayment |
| Rx Tier 1 | $18 copayment (after $500 Rx ded) | $25 copayment | $25 copayment |
| Rx Tier 2 | $500 Rx ded then 60% cov to $500 per Rx | $50 copayment | $55 copayment |
| Rx Tier 3 | $500 Rx ded then 60% cov to $500 per Rx | $125 copayment | $125 copayment |
| Rx Tier 4 | $500 Rx ded then 60% cov to $500 per Rx | 50% cov up to $250 per Rx (after med ded) | 50% cov up to $250 per Rx (after med ded) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Jack | 723.45 | 800.67 | 805.11 |
| Jane Doe | 294.69 | 326.14 | 327.95 |
| Joe Blow | 285.28 fam 947 | 315.73 fam 1048.07 | 317.48 fam 1053.89 |
| Manny | 514.86 fam 985.58 | 569.81 fam 1090.78 | 572.97 fam 1096.83 |
| Moe | 692.82 | 766.77 | 771.03 |
| Total | 2511.10 w deps 3643.54 | 2779.12 w deps 4032.43 | 2794.54 w deps 4054.81 |