SOLO Member Guidebook

Individual HMO High-Deductible Health Plan
For use with Health Savings Account (HSA)
HMO HDHP $5,000/$10,000 Deductible - F
CALENDAR YEAR COST-SHARE In-Network Member Cost
Individual / Family Plan Deductible
(Plan Deductible is combined for health services and prescription drugs)
Lifetime Maximum Benefit
Out-of-pocket Maxumum (Maximum includes all Medical and Prescription services)
$5,000 / $10,000
Unlimited
$6,450 / $12,900
COVERED HEALTH SERVICES In-Network Member Cost
Routine Physical Exam No Member cost (Plan Deductible waived)
Gynecological Preventive Exam Office Services No Member cost (Plan Deductible waived)
Primary Care Providers Office Services No Member cost after Plan Deductible
Specialist Office Services No Member cost after Plan Deductible
Outpatient Laboratory Services No Member cost after Plan Deductible
Non-Advanced Radiology Services No Member cost after Plan Deductible
Advanced Radiology Services(includes MRI, PET and CAT Scan) No Member cost after Plan Deductible
Outpatient Rehabilitative Therapy (up to 40 visits) No Member cost after Plan Deductible
Chiropractic Services (up to 20 visits) No Member cost after Plan Deductible
Walk-In / Urgent Care Services No Member cost after Plan Deductible
Emergency Room No Member cost after Plan Deductible
Emergency Ambulance Services No Member cost after Plan Deductible
Outpatient Ambulatory Services No Member cost after Plan Deductible
Hospitalization for Illness or Injury No Member cost after Plan Deductible
Home Health Services (up to 100 visits) No Member cost after Plan Deductible
Skilled Nursing and Rehabilitation Facilities (up to 90 days) No Member cost after Plan Deductible
Durable Medical Equipment & Disposable Medical Supplies No Member cost after Plan Deductible
PRESCRIPTION DRUG OPTION Tier 1 Tier 2 Tier 3 Tier 4
Option I – 30-Day supply through participating retail pharmacies $5 after Plan Deductible $35 after Plan Deductible 50% after Plan Deductible 50% after Plan Deductible
(Copay is 2X through mail-order) $150 Coins Max per Script $500 Coins Max per Script
HMO HDHP “F” 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.
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