Page 34 - SOLO Member Guidebook

Out-of-Network $4,000 / $8,000 $8,000 / $16,000 30% Unlimited 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 Pl

POS HDHP $2,000/$4,000 Deductible - F Tier 3 20% after Plan Deductible 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 High Deductible Health Plan Options

For use with Health Saving Account (HSA) In-Network $2,000 / $4,000 $6,000 / $12,000 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 Plan Deductible 20% after Plan D

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 Se

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