Zip: 92804	Apply	Apply	Apply
Monthly Total	-112.47	-13.75	25.73
Plan Name	Bronze 60 HMO	Silver 87 HMO	Silver 87 HMO
Deductible	5800 ($11,600 per family)	None	None
Coinsurance	60% coverage for most services	80% coverage most services	80% coverage most services
Out of Pocket Max	$8850 (17,700 family)	$3000 (6000 family)	$3000 (6000 family)
Ambulance	60% coverage (ded applies)	$75 copaymentNot covered	$75 copaymentNot covered
Chiropractic	Not covered
Durable Medical Equipt	60% coverage (ded applies)	85% coverage	85% coverage
Emergency Room	60% coverage (ded applies)	$150 copay	$150 copay
Hospital Stay	60% coverage (ded applies)	80% coverage	80% coverage
Lab & X-ray	$40 lab copay/60% x-ray after ded	$2 lab/$40 x-ray	$2 lab/$40 x-ray
Office Visit	$60 copayment	$15 copayment	$15 copayment
Specialist	$95 copay (ded applies)	$25 copayment	$25 copayment
Physical Therapy	$60 copayment	$15 copayment	$15 copayment
Outpatient Surgery	60% coverage (ded applies)	80% coverage	80% coverage
Psych (Inpatient)	60% coverage after ded	80% coverage	80% coverage
Psych (Outpatient)	$60 copay 1st 3 visits then ded applies	$15 copayment	$15 copayment
Rx Tier 1	$19 copayment	$5 copayment	$5 copayment
Rx Tier 2	60% coverage up to $500 per Rx after $450 Rx ded	$25 copayment	$25 copayment
Rx Tier 3	60% coverage up to $500 per Rx after $450 Rx ded	$45 copayment	$45 copayment
Rx Tier 4	60% coverage up to $500 per Rx after $450 Rx ded	85% coverage up to $150 per Rx	85% coverage up to $150 per Rx
Links	Brochure Providers Formulary	Brochure Providers Formulary	Brochure Providers Formulary
Subscriber (39)	399.06	448.89	468.82
Spouse (37)	391.47	440.36	459.90