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6
IN-NETWORK BENEFITS
SoloCare
40002
Gold
SoloCare
40003
Gold
SoloCare
40007
Silver
Primary Care Physician Office Visit
$20 co-pay
$25 co-pay
$20 copay
Specialist Office Visit
$50 co-pay
$50 co-pay
$20 copay
Urgent Care
$75 co-pay
$75 co-pay
$75 copay
Out-Patient Mental/Behavioral Health
$50 co-pay
Out-Patient Rehabilitation
$50 co-pay
Skilled Nursing Facility
$50 co-pay
Emergency Room Visit
$250 co-pay
$300 co-pay
$300 co-pay
Coinsurance
(after deductible)
100%
90%
55%
Individual/Family Deductible
$1,500/ $3,000
$1,000/ $2,000
$1,750/ $3,500
Individual/Family Out-of-Pocket Maximum $6,850/ $13,700
$6,000/ $12,000
$6,850/ $13,700
PRESCRIPTION DRUG BENEFITS
(after deductible)
Generic Drugs
$15
$15
$15
Preferred Brand Drugs
$50
$50
$50
Non-Preferred Brand
$150
$150
$150
Specialty Drugs
50% co-insurance
after medical
deductible
50% co-insurance
after medical
deductible
50% co-insurance
after medical
deductible
OUT-OF-NETWORK BENEFITS
Coinsurance
(after deductible)
60%
60%
30%
Individual/Family Deductible
$4,500/ $9,000
$3,000/ $6,000
$5,250/ $10,500
Individual/Family Out-of-Pocket Maximum $9,000/ $18,000
$9,000/ $18,000
$18,000/ $36,000
Compare our 40000 series plans
Plans available both ON and OFF the Marketplace.
Plans have the Alliant network.
- Out-of-pocket maximum includes deductible.
- Preventive Care Rx paid 100% - no cost-share for member.
- Plans are NOT HSA Compatible
- Blank cells indicate: subject to deductible and co-insurance