Page 24 - SOLO Member Guidebook
P. 24

Out-of-Network  $5,000 / $10,000  $15,000 / $30,000  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 D




                    POS Upfront Deductible $1,500/$3,000 - 30PCP - 50% - 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













               Coinsurance Plan Options  In-Network  $1,500 / $3,000  $5,500 / $11,000  50%  Unlimited  In-Network Member Cost  No Member cost  No Member cost $30 Copayment per visit (Plan Deductible Waived)  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  50% after Plan Deductible  50% after










                                                                                                      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   Routine Physical Exams Gynecological Preventive Exam Office Services Primary Care Providers Office Services  Specialist Office Services  Outpatient Laboratory Services Non-Advanced Radiology Services Advanced Radiology Services (in












                                                             22
   19   20   21   22   23   24   25   26   27   28   29