|  | |
| Plan | Bronze Select PPO 70/6600/35% | Silver Select HMO 55 |
| Metal | Bronze | Silver |
| Network | Select PPO | Select HMO |
| Deductible | $6600/$13,200 family | None |
| Coinsurance | 65% coverage for most services | Fixed copays for most services |
| Out of Pocket Mzx | $8900/$17,800 family | $9200/$18,400 family |
| Ambulance | 65% coverage (ded applies) | $150 copayment |
| Chiropractor | 50% cov (20 visits max) | $15 copay (30 visits max) |
| Durable Med Equip | 50% coverage (ded applies) | 50% coverage (ded applies) |
| Emergency Room | $250 copay then 65% cov (ded apples) | $500 copayment |
| Hospital | 65% coverage (ded applies) | $750 daily 1st 5 days |
| Infertility | Optional | Optional |
| Lab & X-Ray | 65% coverage (ded applies) | $40 lab/$40 X-ray copayment |
| Office Visit | $70 copay (ded applies) | $55 copayment |
| Specialist | 65% coverage (ded applies) | $110 copayment |
| Outpatient Surgery | $200 copay then 65% cov (ded applies) | $600 copayment |
| Physical Therapy | 65% coverage (ded applies) | $55 copayment |
| Inpatient Psych | 65% coverage (ded applies) | $750 daily 1st 5 days |
| Outpatient Psych | $70 copayment | $55 copayment |
| Rx Tier 1 | $20 copayment | $20 copayment |
| Rx Tier 2 | $80 copay (med ded applies) | $95 copay (after $400 Rx ded) |
| Rx Tier 3 | $120 copayment (med ded applies) | $150 copay (after $400 Rx ded) |
| Rx Tier 4 | 70% coverage to $400 max (med ded applies) | 70% coverage to $250 max ($400 Rx ded applies) |
| Links | Brochure Formulary Providers | Brochure Formulary Providers |
| Jane Doe | 466.43 | 494.72 |
| Joe Blow | 466.43 fam 1419.66 | 494.72 fam 1505.76 |
| Rosemary | 349.91 | 371.13 |
| Total | 1282.77 w deps 2236.00 | 1360.57 w deps 2371.61 |