Prepared for Manohar Delhi PalaceZip code 91744Eff date 3/2020


PlanValue Alliance HMO BR-TW 40%/7200 dedBronze 8150 EPO Option 1Bronze 60 HDHP 6900/0 (shop)
MetalBronzeBronzeBronze
NetworkValue Alliance HMOOscar EPOKaiser Permanente
Deductible$7200/$14,400 family$8150/$16,300 family$6900/$13,800 family
Coinsurance60% coverage (after deductible)100% coverage (after ded)100% coverage for most services
Out of Pocket Mzx$8150 ($16,300 family)$8150 ($16,300 fam)$6900/$13,800 family
Ambulance60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
ChiropractorNot coveredNot coveredNot covered
Durable Med Equip60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Emergency Room60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Hospital60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
InfertilityOptionalOptionalOptional
Lab & X-Ray60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Office Visit60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Specialist60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Outpatient Surgery60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Physical Therapy60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Inpatient Psych60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Outpatient Psych60% coverage (after deductible)100% coverage (after ded)100% coverage (after deductible)
Rx Tier 160% coverage after med ded (max $500)100% coverage (after ded)100% coverage (after deductible)
Rx Tier 260% coverage after med ded (max $500)100% coverage (after ded)100% coverage (after deductible)
Rx Tier 360% coverage after med ded (max $500)100% coverage (after ded)100% coverage (after deductible)
Rx Tier 460% coverage after med ded (max $500)100% coverage (after ded)100% coverage (after deductible)
LinksBrochure Formulary ProvidersBrochure Formulary ProvidersBrochure Formulary Providers
Barney Rubble349.12352.07353.14
Bhatia, Jenny228.99230.93231.63
Jane Doe436.91440.6441.95
Joe Blow295.5298298.91
Manohar Lal604.1 fam 1265.09609.2 fam 1275.78611.06 fam 1279.67
Tiny Tim245.16247.23247.99
Total2159.78 w deps 2820.772178.03 w deps 2844.612184.68 w deps 2853.29