Page 35 - SOLO Member Guidebook

Out-of-Network $6,000 / $12,000 $10,000 / $20,000 30% Unlimited Tier 4 No Member costs after Plan Deductible

/$6,000 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 Deductible 30

POS HDHP $3,000 Tier 3 No Member costs 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

In-Network $3,000 / $6,000 $3,000 / $6,000 Not applicable Unlimited Tier 2 No Member costs after Plan Deductible

For use with Health Saving Account (HSA) In-Network Member Cost No Member cost No Member cost 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 Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Member cost after Plan Deductible No Me

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 (Cost-shares for the following services are the same for both plan options.) Routine Physical Exam Gynecological Preventive Exam Office Services Primary Care Pro

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