SOLO Member Guidebook

Individual POS Upfront Deductible Plan Options
Coinsurance Plan Options
POS Upfront Deductible $1,500/$3,000 - 20% - F
CALENDAR YEAR COST-SHARE In-Network Out-of-Network
Individual / Family Plan Deductible $1,500 / $3,000 $4,000 / $8,000
Individual / Family Out-of-Pocket Maximum
(Maximum includes all Medical and Prescription Services)
$5,500 / $11,000 $10,000 / $20,000
Member Coinsurance 20% 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 20% after Plan Deductible 50% after Plan Deductible
Specialist Office Services 20% after Plan Deductible 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) 20% after Plan Deductible 50% after Plan Deductible
Chiropractic Services (up to 20 visits) 20% after Plan Deductible 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
Outpatient Ambulatory Services 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
$60 ($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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