Page 29 - SOLO Member Guidebook
P. 29

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% (Plan De





                   POS Upfront Deductible $2,500/$5,000 - 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.




















             Coinsurance Plan Options Individual POS Upfront Deductible Plan Options  In-Network  $2,500 / $5,000  $5,000 / $10,000  20%  Unlimited  In-Network Member Cost  No Member cost  No Member cost  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Plan Deductible  20% after Pla











                                                                                                  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 plan options.)  Routine Physical Exam Gynecological Preventive Exam Office Services Primary Care Providers Office Services  Specialist Office Services  Outpatient Laboratory












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