SOLO Member Guidebook

Individual POS DEDUCTIBLE PLAN OPTIONS
POS Deductible $2,500/$5,000 - F
CALENDAR YEAR COST-SHARE In-Network Out-of-Network
Individual / Family Plan Deductible $2,500 / $5,000 $5,000 / $10,000
Individual / Family Out-of-Pocket Maximum
(Maximum includes all Medical and Prescription services)
$5,700 / $11,400 $10,000 / $20,000
Member Coinsurance Not applicable 50%
Lifetime Maximum Benefit Unlimited Unlimited
COVERED HEALTH SERVICES In-Network Member Cost Out-of-Network Member Cost
Routine Physical Exam No Member cost 50% after Plan Deductible
Gynecological Preventive Exam Office Services No Member cost 50% after Plan Deductible
Primary Care Providers Office Services $25 Copayment per visit 50% after Plan Deductible
Specialist Office Services $45 Copayment per visit 50% after Plan Deductible
Outpatient Laboratory Services No Member cost 50% after Plan Deductible
Non-Advanced Radiology Services $45 Copayment per visit 50% after Plan Deductible
Advanced Radiology Services (includes MRI, PET and CAT Scan) $75 Copayment per visit up to 5 Copayments per year 50% after Plan Deductible
Outpatient Rehabilitative Therapy (up to 40 visits) $30 Copayment per visit 50% after Plan Deductible
Chiropractic Services (up to 20 visits) $45 Copayment per visit 50% after Plan Deductible
Walk-In / Urgent Care Services $75 Copayment per visit Same as In-Network
Emergency Room $150 Copayment per visit Same as In-Network
Emergency Ambulance Services No Member cost Same as In-Network
Outpatient Ambulatory Services No Member cost after Plan Deductible 50% after Plan Deductible
Hospitalization for Illness or Injury No Member cost after Plan Deductible 50% after Plan Deductible
Home Health Services (up to 100 visits) $30 Copayment per visit 25% (Plan Deductible Waived)
Skilled Nursing and Rehabilitation Facilities (up to 90 days) No Member cost after Plan Deductible 50% after Plan Deductible
Durable Medical Equipment & Disposable Medical Supplies 50% 50% after Plan Deductible
POS DED PLANS – 1 OF 2 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.
SOLO POS Plans 0914
14