Page 16 - SOLO Member Guidebook

SOLO POS Plans 0914

Out-of-Network $5,000 / $10,000 $10,000 / $20,000 50% Unlimited Out-of-Network Member Cost 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible Same as In-Network Same as In-Network Same as In-Network 50% after Plan Deductible 50% after Plan Deductible 25% (Pl

POS Deductible $2,500/$5,000 - F

Individual POS DEDUCTIBLE PLAN OPTIONS

In-Network $2,500 / $5,000 $5,700 / $11,400 Not applicable Unlimited In-Network Member Cost No Member cost No Member cost $25 Copayment per visit $45 Copayment per visit No Member cost $45 Copayment per visit $75 Copayment per visit up to 5 Copayments per year $30 Copayment per visit $45 Copayment per visit $75 Copayment per visit $150 Copayment per visit No Member cost No Member cost after Plan Deductible No Member cost after Plan Deductib

CALENDAR YEAR COST-SHARE Individual / Family Plan Deductible Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) Member Coinsurance Lifetime Maximum Benefit COVERED HEALTH SERVICES Routine Physical Exam Gynecological Preventive Exam Office Services Primary Care Providers Office Services Specialist Office Services Outpatient Laboratory Services Non-Advanced Radiology Services Advanced Radiology Services

14