|  |  |  |  |  |
| Plan | Value Alliance HMO BR-TW 40%/7200 ded | Bronze 8150 EPO Option 1 | SmartCare HMO Gold $30 | Trio Gold 80 HMO 250/25 w Child Dental (shop) | Platinum HMO 25 4HTT |
| Metal | Bronze | Bronze | Gold | Gold | Platinum |
| Network | Value Alliance HMO | Oscar EPO | SmartCare HMO | Trio ACO Network | CaliforniaCare HMO |
| Deductible | $7200/$14,400 family | $8150/$16,300 family | None | $250/$500 family | None |
| Coinsurance | 60% coverage (after deductible) | 100% coverage (after ded) | 70% coverage for most services | Fixed copays for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8150 ($16,300 family) | $8150 ($16,300 fam) | $6000/$12,000 family | $7800/$15,600 family | $2200/$4400 family |
| Ambulance | 60% coverage (after deductible) | 100% coverage (after ded) | $300 copayment | $250 copayment | $150 copaylment |
| Chiropractor | Not covered | Not covered | Optional | Not covered | $20 copayment (20 visits max) |
| Durable Med Equip | 60% coverage (after deductible) | 100% coverage (after ded) | 70% coverage | 80% coverage | $100 copayment |
| Emergency Room | 60% coverage (after deductible) | 100% coverage (after ded) | $300 copayment | $250 copayment | $250 copayment |
| Hospital | 60% coverage (after deductible) | 100% coverage (after ded) | $750 per day (1st 3 days) | $600 per day 1st 5 days | $400 daily 1st 4 days |
| Infertility | Optional | Optional | Optional | Not covered | Optional |
| Lab & X-Ray | 60% coverage (after deductible) | 100% coverage (after ded) | Lab: $40 copay/X-ray $40 copay | $25 lab/$65 X-ray | $15 lab/$30 X-ray copayment |
| Office Visit | 60% coverage (after deductible) | 100% coverage (after ded) | $30 copayment | $25 copayment | $25 copayment |
| Specialist | 60% coverage (after deductible) | 100% coverage (after ded) | $50 copayment | $65 copayment | $40 copayment |
| Outpatient Surgery | 60% coverage (after deductible) | 100% coverage (after ded) | $900 copayment | $300 copayment | $200 copayment |
| Physical Therapy | 60% coverage (after deductible) | 100% coverage (after ded) | $30 copayment | $25 copayment | $25 copayment |
| Inpatient Psych | 60% coverage (after deductible) | 100% coverage (after ded) | $750 per day (1st 3 days) | $600 per day 1st 5 days | $400 daily 1st 4 days |
| Outpatient Psych | 60% coverage (after deductible) | 100% coverage (after ded) | $30 copayment | $25 copayment | $25 copayment |
| Rx Tier 1 | 60% coverage after med ded (max $500) | 100% coverage (after ded) | $5 copayment | $15 copayment | $15 coayment |
| Rx Tier 2 | 60% coverage after med ded (max $500) | 100% coverage (after ded) | $30 copayment | $50 copayment | $35 copayment |
| Rx Tier 3 | 60% coverage after med ded (max $500) | 100% coverage (after ded) | $50 copayment | $80 copayment | $70 copayment |
| Rx Tier 4 | 60% coverage after med ded (max $500) | 100% coverage (after ded) | 30% (up to $250 per 30 day script after ded) | 80% coverage up to $250 per Rx | 70% coverage to $250 max |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| Leon Spinks | 334.28 fam 1167.09 | 346.44 fam 1209.55 | 461.93 fam 1612.76 | 473 fam 1651.41 | 666.78 fam 2327.96 |
| Terry Bradshaw | 261.35 | 270.86 | 361.15 | 369.8 | 521.31 |
| Total | 595.63 w deps 1428.44 | 617.30 w deps 1480.41 | 823.08 w deps 1973.91 | 842.80 w deps 2021.21 | 1188.09 w deps 2849.27 |