Page 31 - SOLO Member Guidebook

50% after Plan Deductible $500 Coins Max per Script

Tier 4

HMO HDHP $5,000/$10,000 Deductible - F In-Network Member Cost $5,000 / $10,000 Unlimited $6,450 / $12,900 In-Network Member Cost No Member cost (Plan Deductible waived) No Member cost (Plan Deductible waived) No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan

Individual HMO High-Deductible Health Plan

$35 after Plan Deductible
For use with Health Savings Account (HSA)

Tier 2

$5 after Plan Deductible

Tier 1

CALENDAR YEAR COST-SHARE Individual / Family Plan Deductible (Plan Deductible is combined for health services and prescription drugs) Lifetime Maximum Benefit Out-of-pocket Maxumum (Maximum includes all Medical and Prescription services) 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

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