Page 33 - SOLO Member Guidebook

Out-of-Network $3,000 / $6,000 $7,000 / $14,000 30% Unlimited Tier 4 50% after Plan Deductible $500 Coins Max per Script

POS HDHP $1,500/$3,000 Deductible - F Out-of-Network Member Cost 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible 30% after Plan Deductible Same as In-Network Same as In-Network Same as In-Network 30% after Plan Deductible 30% after Plan Deductible 25% after Plan Deductible 30% after Plan De

Individual POS High Deductible Health Plan Options

In-Network $1,500 / $3,000 $6,350 / $12,700 Not Applicable Unlimited

For use with Health Saving Account (HSA) In-Network Member Cost No Member cost No Member cost $30 Copayment per visit after Plan Deductible $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 Deductible $75 Copayment per visit after Pl

CALENDAR YEAR COST-SHARE Individual / Family Plan Deductible (Deductible is combined for health services and prescription drugs) 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 Servic

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