Page 27 - SOLO Member Guidebook

Out-of-Network $10,000 / $20,000 $12,500 / $25,000 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

POS Copay and Deductible $5,000/$10,000 - 20% - 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 $5,000 / $10,000 $6,350 / $12,700 20% when applicable Unlimited In-Network Member Cost No Member cost No Member cost $30 Copayment per visit (Plan Deductible Waived) $45 Copayment per visit (Plan Deductible Waived) 20% after Plan Deductible 20% after Plan Deductible 20% after Plan Deductible $30 Copayment per visit (Plan Deductible Waived) $45 Copayment per visit (Plan Deductible Waived) 20% after Plan Deductible 20% after Plan Deductibl

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

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