SOLO Member Guidebook

Individual POS Upfront Deductible Plan Options
CALENDAR YEAR COST-SHARE
Individual / Family Plan Deductible
Individual / Family Out-of-Pocket Maximum
(Maximum includes all Medical and Prescription services)
Member Coinsurance
Lifetime Maximum Benefit
POS Upfront Deductible $1,000/$2,000 - F
In-Network Out-of-Network
$1,000 / $2,000 $3,000 / $6,000
$6,350 / $12,700 $7,000 / $14,000
Not applicable 50%
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 (Plan Deductible Waived) 50% after Plan Deductible
Specialist Office Services $45 Copayment per visit after Plan Deductible 50% after Plan Deductible
Outpatient Laboratory Services No Member cost after Plan Deductible 50% after Plan Deductible
Non-Advanced Radiology Services $45 Copayment per visit after Plan Deductible 50% after Plan Deductible
Advanced Radiology Services (includes MRI, PET and CAT Scan)
$75 Copayment per visit up to 5 Copayments
per year after Plan Deductible
50% after Plan Deductible
Outpatient Rehabilitative Therapy (up to 40 visits) $30 Copayment per visit after Plan Deductible 50% after Plan Deductible
Chiropractic Services (up to 20 visits) $45 Copayment per visit after Plan Deductible 50% after Plan Deductible
Walk-In / Urgent Care Services $75 Copayment per visit after Plan Deductible Same as In-Network
Emergency Room $150 Copayment per visit after Plan Deductible Same as In-Network
Emergency Ambulance Services No Member cost after Plan Deductible Same as In-Network
Outpatient Ambulatory Services (hospital facility) $500 Copayment per visit after Plan Deductible 50% after Plan Deductible
Hospitalization for Illness or Injury
$500 Copayment per day up to $2,000 per admit
after Plan Deductible
50% after Plan Deductible
Home Health Services (up to 100 visits) $30 Copayment per visit (Plan Deductible Waived) 25% (Plan Deductible Waived)
Skilled Nursing and Rehabilitation Facilities (up to 90 days)
$500 Copayment per day up to $2,000 per admit
after Plan Deductible
50% after Plan Deductible
Durable Medical Equipment & Disposable Medical Supplies 50% after Plan Deductible 50% after Plan Deductible
PRESCRIPTION DRUG OPTION Tier 1 Tier 2 Tier 3 Tier 4
Option I – 30-Day supply through participating retail pharmacies $5
$40 ($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 UPFRONT DED “F” PLANS – 1 OF 1
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.
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