Page 36 - SOLO Member Guidebook

Out-of-Network $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% after Plan Deductibl

POS-HDHP $5,000/$10,000 Combined Deductible - F $5,000 / $10,000 Tier 3 50% after Plan 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.

Individual POS Combined High Deductible Health Plan

For use with Health Saving Account (HSA) In-Network $6,450 / $12,900 Not Applicable Unlimited 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 afte

CALENDAR YEAR COST-SHARE Individual / Family Plan Deductible (Deductible is combined for In- and Out-of-Network 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 Service

34 In-network