|  | | |
| Plan | Bronze 60 HMO 5400/60 (shop) | Silver 70 HMO 2600/55 (shop) | Gold 80 HMO 250/35 (shop) |
| Metal | Bronze | Silver | Gold |
| Network | Kaiser Permanente | Kaiser Permanente | Kaiser Permanente |
| Deductible | $5400/$10,800 family | $2600/$5200 family | $250 ($500 family) |
| Coinsurance | 50% coverage for most services | 55% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8200/16,400 family | $8200/16,400 family | $7800/15,600 family |
| Ambulance | 50% coverage (after ded) | 55% coverage (ded applies) | $250 copayment (after ded) |
| Chiropractor | Not covered | Not covered | Not covered |
| Durable Med Equip | 50% coverage (after ded) | 55% coverage | 80% coverage (after ded) |
| Emergency Room | 50% coverage (after ded) | 55% coverage (ded applies) | $250 copayment (after ded) |
| Hospital | 50% coverage (after ded) | 55% coverage (ded applies) | $600 per day 1st 5 days |
| Infertility | Optional | Optional | Optional |
| Lab & X-Ray | 50% coverage (after ded) | $30 lab/$75 X-ray | $35 lab/$55 X-ray |
| Office Visit | $60 copay first 3 visits then deductible applies | $55 copayment | $35 copayment |
| Specialist | $80 copay first 3 visits then deductible applies | $80 copayment | $55 copayment |
| Outpatient Surgery | 50% coverage (after ded) | 55% coverage (ded applies) | $335 copayment |
| Physical Therapy | $65 copayment | $65 copayment | $35 copayment |
| Inpatient Psych | 50% coverage (after ded) | 55% coverage (ded applies) | $600 per day 1st 5 days |
| Outpatient Psych | $60 copay first 3 visits then deductible applies | $55 copayment | $35 copayment |
| Rx Tier 1 | $20 copay | $20 copay | $15 copayment |
| Rx Tier 2 | 50% coverage to $500 (med ded applies) | $75 copay (after med ded) | $40 copayment |
| Rx Tier 3 | 50% coverage to $500 (med ded applies) | $75 copay (after med ded) | $40 copayment |
| Rx Tier 4 | 50% coverage to $500 (med ded applies) | 55% coverage to $250 (plan ded applies) | 80% coverage to $250 |
| Links | Brochure Formulary Providers | Brochure Formulary Providers | Brochure Formulary Providers |
| ee1 | 357.97 | 416.15 | 504.1 |
| ee2 | 583.57 | 678.41 | 821.78 |
| ee3 | 285.37 | 331.75 | 401.86 |
| ee4 | 467.22 | 543.15 | 657.94 |
| ee5 | 256.28 | 297.93 | 360.9 |
| Total | 1950.41 | 2267.39 | 2746.58 |