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SOLO Member Guidebook

Individual POS

Individual POS DEDUCTIBLE PLAN OPTIONS POS Deductible $5,000/$10,000 - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible $5,000 / $10,000 $5,000 / $10,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) $6,600 / $13,200 $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 $30 Copayment per visit 50% after Plan Deductible Specialist Office Services $50 Copayment per visit 50% after Plan Deductible Outpatient Laboratory Services $30 Copayment per visit 50% after Plan Deductible Non-Advanced Radiology Services $50 Copayment per visit 50% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) $75 Copayment per visit after Plan Deductable 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) $50 Copayment per visit 50% after Plan Deductible Walk-In / Urgent Care Services $75 Copayment per visit Same as In-Network Emergency Room $200 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. 16

PRESCRIPTION DRUG OPTION Tier 1 Tier 2 Tier 3 Tier 4 Option I – 30-Day supply through participating retail pharmacies $5 $50 ($200 Deductible) 50% ($200 Deductible) 50% ($200 Deductible) (Copay is 2X through mail-order) $150 Coins Max per Script $500 Coins Max per Script POS DED PLANS – 2 OF 2 17

SOLO Member Guidebook - ConnectiCare
Member Guidebook - For ConnectiCare SOLO Individual Health Plans
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