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SOLO Member Guidebook

Individual POS High

Individual POS High Deductible Health Plan Options For use with Health Saving Account (HSA) POS HDHP $2,000/$4,000 Deductible - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible (Deductible is combined for health services and prescription drugs) $2,000 / $4,000 $4,000 / $8,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) $6,000 / $12,000 $8,000 / $16,000 Member Coinsurance 20% 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 20% after Plan Deductible 30% after Plan Deductible Specialist Office Services 20% after Plan Deductible 30% after Plan Deductible Outpatient Laboratory Services 20% after Plan Deductible 30% after Plan Deductible Non-Advanced Radiology Services 20% after Plan Deductible 30% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) 20% after Plan Deductible 30% after Plan Deductible Outpatient Rehabilitative Therapy (up to 40 visits) 20% after Plan Deductible 30% after Plan Deductible Chiropractic Services (up to 20 visits) 20% after Plan Deductible 30% 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 30% after Plan Deductible Hospitalization for Illness or Injury 20% after Plan Deductible 30% after Plan Deductible Home Health Services (up to 100 visits) 20% after Plan Deductible 25% after Plan Deductible Skilled Nursing and Rehabilitation Facilities (up to 90 days) 20% after Plan Deductible 30% after Plan Deductible Durable Medical Equipment & Disposable Medical Supplies 20% 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) 20% after Plan Deductible 20% after Plan Deductible 20% after Plan Deductible 20% after Plan Deductible POS HDHP “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. 32

Individual POS High Deductible Health Plan Options For use with Health Saving Account (HSA) POS HDHP $3,000 /$6,000 Deductible - F CALENDAR YEAR COST-SHARE In-Network Out-of-Network Individual / Family Plan Deductible (Deductible is combined for health services and prescription drugs) $3,000 / $6,000 $6,000 / $12,000 Individual / Family Out-of-Pocket Maximum (Maximum includes all Medical and Prescription services) $3,000 / $6,000 $10,000 / $20,000 Member Coinsurance Not applicable 30% Lifetime Maximum Benefit Unlimited Unlimited COVERED HEALTH SERVICES (Cost-shares for the In-Network Member Cost Out-of-Network Member Cost following services are the same for both plan options.) 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 No Member cost after Plan Deductible 30% after Plan Deductible Specialist Office Services No Member cost after Plan Deductible 30% after Plan Deductible Outpatient Laboratory Services No Member cost after Plan Deductible 30% after Plan Deductible Non-Advanced Radiology Services No Member cost after Plan Deductible 30% after Plan Deductible Advanced Radiology Services (includes MRI, PET and CAT Scan) No Member cost after Plan Deductible 30% after Plan Deductible Outpatient Rehabilitative Therapy (up to 40 visits) No Member cost after Plan Deductible 30% after Plan Deductible Chiropractic Services (up to 20 visits) No Member cost after Plan Deductible 30% after Plan Deductible Walk-In / Urgent Care Services No Member cost after Plan Deductible Same as In-Network Emergency Room No Member cost after Plan Deductible Same as In-Network Emergency Ambulance Services No Member cost after Plan Deductible Same as In-Network Outpatient Ambulatory Services No Member cost after Plan Deductible 30% after Plan Deductible Hospitalization for Illness or Injury No Member cost after Plan Deductible 30% after Plan Deductible Home Health Services (up to 100 visits) No Member cost after Plan Deductible 25% after Plan Deductible Skilled Nursing and Rehabilitation Facilities (up to 90 days) No Member cost after Plan Deductible 30% after Plan Deductible Durable Medical Equipment & Disposable Medical Supplies No Member cost 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) No Member costs after Plan Deductible No Member costs after Plan Deductible No Member costs after Plan Deductible No Member costs after Plan Deductible POS 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. 33

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