|  | |
| Plan | SmartCare HMO Platinum $0 | Bronze PPO 6300/65 |
| Metal | Platinum | Bronze |
| Network | SmartCare HMO | Full PPO |
| Deductible | None | $6300/$12,600 famly |
| Coinsurance | Fixed copays for most services | 60% coverage for most services |
| Out of Pocket Mzx | $3150/$6300 family | $8200/$16,400 family |
| Ambulance | $250 copayment (ded applies) | 60% coverage (ded applies) |
| Chiropractor | Optional | Optional |
| Durable Med Equip | 70% coverage | 60% coverage (ded applies) |
| Emergency Room | $250 copayment (ded applies) | 60% coverage (ded applies) |
| Hospital | $500 per day (1st 4 days) | 60% coverage (ded applies) |
| Infertility | Optional | Optional |
| Lab & X-Ray | No charge | Lab: $40 copay (ded waived)/X-ray $60% cov (ded applies) |
| Office Visit | No charge | $65 copay 1st 3 visits then ded applies |
| Specialist | No charge | $95 copay 1st 3 visits then ded applies |
| Outpatient Surgery | $150 or $400 copay | 60% coverage (ded applies) |
| Physical Therapy | No charge | $65 copayment |
| Inpatient Psych | $500 per day (1st 4 days) | 60% coverage (ded applies) |
| Outpatient Psych | No charge | $95 copay 1st 3 visits then ded applies |
| Rx Tier 1 | No charge | $18 copay after $500 Rx ded |
| Rx Tier 2 | $30 copayment | 60% cov after $500 Rx ded |
| Rx Tier 3 | $50 copayment | 60% cov after $500 Rx ded |
| Rx Tier 4 | 70% coverage | 60% cov up to $500 after $500 Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Jane Doe | 407.63 fam 1586.17 | 408.95 fam 1591.3 |
| Jose A | 595.77 fam 1008.74 | 597.7 fam 1012.01 |
| Total | 1003.40 w deps 2594.91 | 1006.65 w deps 2603.31 |