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SOLO Member Guidebook

Individual POS Upfront

Individual POS Upfront Deductible Plan Options Coinsurance Plan Options POS Upfront Deductible $5,000/$10,000 - 30PCP-50% - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible $5,000 / $10,000 $10,000 / $20,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription Services) $6,350 / $12,700 $20,000 / $40,000 Member Coinsurance 50% 50% Lifetime Maximum Benefit Unlimited Unlimited COVERED HEALTH SERVICES In-Network Member Cost Out-of-Network Member Cost Routine Physical Exams 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 50% after Plan Deductible 50% after Plan Deductible Outpatient Laboratory Services 50% after Plan Deductible 50% after Plan Deductible Non-Advanced Radiology Services 50% after Plan Deductible 50% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) 50% after Plan Deductible 50% after Plan Deductible Outpatient Rehabilitative Therapy (up to 40 visits) 50% after Plan Deductible 50% after Plan Deductible Chiropractic Services (up to 20 visits) 50% after Plan Deductible 50% after Plan Deductible Walk-In / Urgent Care Services 50% after Plan Deductible Same as In-Network Emergency Room 50% after Plan Deductible Same as In-Network Emergency Ambulance Services 50% after Plan Deductible Same as In-Network Outpatient Ambulatory Services 50% after Plan Deductible 50% after Plan Deductible Hospitalization for Illness or Injury 50% after Plan Deductible 50% after Plan Deductible Home Health Services (up to 100 visits) 25% (Plan Deductible Waived) 25% (Plan Deductible Waived) Skilled Nursing and Rehabilitation Facilities (up to 90 days) 50% 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 $20 ($200 Deductible) $60 ($200 Deductible) 50% ($200 Deductible) (Copay is 2X through mail-order) $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. 24

Individual POS Upfront Deductible Plan Options POS Copay and Deductible $5,000/$10,000 - 20% - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible $5,000 / $10,000 $10,000 / $20,000 $6,350 / $12,700 $12,500 / $25,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription Services) Member Coinsurance 20% when 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 (Plan Deductible Waived) 50% after Plan Deductible Specialist Office Services $45 Copayment per visit (Plan Deductible Waived) 50% after Plan Deductible Outpatient Laboratory Services 20% after Plan Deductible 50% after Plan Deductible Non-Advanced Radiology Services 20% after Plan Deductible 50% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) 20% after Plan Deductible 50% after Plan Deductible Outpatient Rehabilitative Therapy (up to 40 visits) $30 Copayment per visit (Plan Deductible Waived) 50% after Plan Deductible 25 Chiropractic Services (up to 20 visits) $45 Copayment per visit (Plan Deductible Waived) 50% after Plan Deductible Walk-In / Urgent Care Services 20% after Plan Deductible Same as In-Network Emergency Room 20% after Plan Deductible Same as In-Network Emergency Ambulance Services 20% after Plan Deductible Same as In-Network Ambulatory Services (Outpatient) 20% after Plan Deductible 50% after Plan Deductible Hospitalization for Illness or Injury 20% after Plan Deductible 50% after Plan Deductible Home Health Services (up to 100 visits) 20% (Plan Deductible Waived) 25% (Plan Deductible Waived) Skilled Nursing and Rehabilitation Facilities (up to 90 days) 20% 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 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. POS UPFRONT DED “F” PLANS – 1 OF 1

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