SOLO Member Guidebook

Individual POS High Deductible Health Plan Options
For use with Health Saving Account (HSA)
POS HDHP $1,500/$3,000 Deductible - F
CALENDAR YEAR COST-SHARE In-Network Out-of-Network
Individual / Family Plan Deductible (Deductible is combined for health services and prescription drugs) $1,500 / $3,000 $3,000 / $6,000
Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) $6,350 / $12,700 $7,000 / $14,000
Member Coinsurance Not Applicable 30%
Lifetime Maximum Benefit Unlimited Unlimited
COVERED HEALTH SERVICES In-Network Member Cost Out-of-Network Member Cost
Routine Physical Exam No Member cost 30% after Plan Deductible
Gynecological Preventive Exam Office Services No Member cost 30% after Plan Deductible
Primary Care Providers Office Services $30 Copayment per visit after Plan Deductible 30% after Plan Deductible
Specialist Office Services $45 Copayment per visit after Plan Deductible 30% after Plan Deductible
Outpatient Laboratory Services No Member cost after Plan Deductible 30% after Plan Deductible
Non-Advanced Radiology Services $45 Copayment per visit after Plan Deductible 30% 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
30% after Plan Deductible
Outpatient Rehabilitative Therapy (up to 40 visits) $30 Copayment per visit after Plan Deductible 30% after Plan Deductible
Chiropractic Services (up to 20 visits) $45 Copayment per visit after Plan Deductible 30% 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 30% after Plan Deductible
Hospitalization for Illness or Injury
$500 Copayment per day up to $2,000 per admit
after Plan Deductible
30% after Plan Deductible
Home Health Services (up to 100 visits) $30 Copayment after Plan Deductible 25% after Plan Deductible
Skilled Nursing and Rehabilitation Facilities (up to 90 days)
$500 Copayment per day up to $2,000 per admit
after Plan Deductible
30% after Plan Deductible
Durable Medical Equipment & Disposable Medical Supplies 50% after Plan Deductible 30% after Plan Deductible
PRESCRIPTION DRUG OPTION Tier 1 Tier 2 Tier 3 Tier 4
In-network
Retail Pharmacy (up to a 30-day supply for prescriptions)
(Copay is 2X through mail-order)
$5 after Plan Deductible $40 after Plan Deductible
50% after Plan Deductible
$150 Coins Max per Script
50% after Plan Deductible
$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 HDHP “F” PLANS – 1 OF 1
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