|  |
| Plan | Bronze 60 HMO 6300/65 (shop) |
| Metal | Bronze |
| Network | Kaiser Permanente |
| Deductible | $6300/$12,600 family |
| Coinsurance | 60% coverage for most services |
| Out of Pocket Mzx | $7800/15,600 family |
| Ambulance | 60% coverage (after ded) |
| Chiropractor | Not covered |
| Durable Med Equip | 60% coverage (after ded) |
| Emergency Room | 60% coverage (after ded) |
| Hospital | 60% coverage (after ded) |
| Infertility | Optional |
| Lab & X-Ray | Lab $40/X-ray 60% coverage (after ded) |
| Office Visit | $65 copayment first 3 visits then deductible applies |
| Specialist | $95 copayment first 3 visits then deductible applies |
| Outpatient Surgery | 60% coverage (after ded) |
| Physical Therapy | $65 copayment |
| Inpatient Psych | 60% coverage (after ded) |
| Outpatient Psych | $65 copayment first 3 visits then deductible applies |
| Rx Tier 1 | $500 Rx ded then $18 ded per Rx |
| Rx Tier 2 | $500 Rx ded then $500 max ben per Rx |
| Rx Tier 3 | $500 Rx ded then $500 max ben per Rx |
| Rx Tier 4 | $500 Rx ded then $500 max ben per Rx |
| Links | Brochure Formulary Providers |
| Leon Spinks | 339.12 fam 524.82 |
| Total | 339.12 w deps 524.82 |