Page 21 - SOLO Member Guidebook

Out-of-Network $3,000 / $6,000 $7,000 / $14,000 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% (Plan Ded

POS Upfront Deductible $750/$1,500 - F Tier 3 50% ($200 Deductible) $150 Coins Max per Script Rates displayed are quoted rates only. Final rates are subject to Department of Insurance approval. Rates and benefits are subject to change based on any state or federal mandate or other regulatory requirements.

Individual POS Upfront Deductible Plan Options

In-Network $750 / $1,500 $6,350 / $12,700 Not applicable Unlimited In-Network Member Cost No Member cost No Member cost $30 Copayment per visit (Plan Deductible Waived) $45 Copayment per visit after Plan Deductible No Member cost after Plan Deductible $45 Copayment per visit after Plan Deductible $75 Copayment per visit up to 5 Copayments per year after Plan Deductible $30 Copayment per visit after Plan Deductible $45 Copayment per visit after Plan De

Tier 1 $5

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 (Cost-shares for the following services are the same for all three plan options.) Routine Physical Exam Gynecological Preventive Exam Office Services Primary Care Providers Office Services Specialist Office Services Outpatient Lab

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