|  |  | |
| Plan | Bronze PPO 6950/0% w/HSA 5SU5 | Bronze 60 PPO 6300/65 + Child Dental | Bronze 60 HDHP PPO 7000/0% + Child Dental |
| Metal | Bronze | Bronze | Bronze |
| Network | Prudent Buyer PPO | Full PPO | Full PPO |
| Deductible | $6950/$13,900 family | $6300/$12,600 famly | $7000/$14,000 family |
| Coinsurance | 100% coverage after ded | 60% coverage for most services | 100% coverage for most services |
| Out of Pocket Mzx | $6950/$13,900 family | $8200/$16,400 family | $7000/$14,000 family |
| Ambulance | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Chiropractor | 20 visits max | Optional | Optional |
| Durable Med Equip | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Emergency Room | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Hospital | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 100% coverage after ded | Lab: $40 copay (ded waived)/X-ray $60% cov (ded applies) | 100% coverage (ded applies) |
| Office Visit | 100% coverage after ded | $65 copay 1st 3 visits then ded applies | 100% coverage (ded applies) |
| Specialist | 100% coverage after ded | $95 copay 1st 3 visits then ded applies | 100% coverage (ded applies) |
| Outpatient Surgery | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Physical Therapy | 100% coverage after ded | $65 copayment | 100% coverage (ded applies) |
| Inpatient Psych | 100% coverage after ded | 60% coverage (ded applies) | 100% coverage (ded applies) |
| Outpatient Psych | 100% coverage after ded | $95 copay 1st 3 visits then ded applies | 100% coverage (ded applies) |
| Rx Tier 1 | 100% coverage after ded | $18 copay after ded | 100% coverage (ded applies) |
| Rx Tier 2 | 100% coverage after ded | 60% cov up to $500 per Rx after Rx ded | 100% coverage (ded applies) |
| Rx Tier 3 | 100% coverage after ded | 60% cov up to $500 per Rx after Rx ded | 100% coverage (ded applies) |
| Rx Tier 4 | 100% coverage after ded | 60% cov up to $500 per Rx after Rx ded | 100% coverage (ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Jose A | 296.85 | 313.13 | 313.89 |
| Total | 296.85 | 313.13 | 313.89 |