|  |  |
| Plan | Bronze 60 HMO HSA (shop) | WholeCare HMO Silver $55 |
| Metal | Bronze | Silver |
| Network | Kaiser Permanente | Wholecare HMO |
| Deductible | $6650/$13,300 family | None |
| Coinsurance | 100% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $6650/$13,300 family | $9200/$18,400 family |
| Ambulance | 100% coverage (after deductible) | 50% coverage |
| Chiropractor | Full coverage if physician referral (ded applies) | Not Covered |
| Durable Med Equip | 100% coverage (after deductible) | 50% coverage |
| Emergency Room | 100% coverage (after deductible) | 50% coverage |
| Hospital | 100% coverage (after deductible) | $750 per day (1st 5 days) |
| Infertility | Optional | Optional |
| Lab & X-Ray | 100% coverage (after deductible) | Lab: $40 copay/X-ray $60 copay |
| Office Visit | 100% coverage (after deductible) | $55 copayment |
| Specialist | 100% coverage (after deductible) | $90 copayment |
| Outpatient Surgery | 100% coverage (after deductible) | 50% coverage |
| Physical Therapy | 100% coverage (after deductible) | $55 copayment |
| Inpatient Psych | 100% coverage (after deductible) | $750 per day (1st 5 days) |
| Outpatient Psych | 100% coverage (after deductible) | $55 copayment |
| Rx Tier 1 | 100% coverage (after deductible) | $20 copayment |
| Rx Tier 2 | 100% coverage (after deductible) | 50% cov up to $250 after Rx ded |
| Rx Tier 3 | 100% coverage (after deductible) | 50% cov up to $250 after Rx ded |
| Rx Tier 4 | 100% coverage (after deductible) | 50% cov up to $250 after Rx ded |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Jane Doe | 368.19 | 386.31 |
| Joe Blow | 429.35 fam 1334.79 | 450.48 fam 1371.1 |
| Total | 797.54 w deps 1702.98 | 836.79 w deps 1757.41 |