SoloCare - 2016 Individual & Family Plan Brochure

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Compare our 60000 series plans
Plans available only OFF the Marketplace. Plans have the Alliant network plus the PHCS network wrap.
IN-NETWORK BENEFITS
SoloCare
60023
Gold
SoloCare
60024
Gold
SoloCare
60028
Silver
Primary Care Physician Office Visit $20 co-pay $25 co-pay $20 co-pay
Specialist Office Visit $50 co-pay $50 co-pay $20 co-pay
Urgent Care $75 co-pay $75 co-pay $75 co-pay
Out-Patient Mental/Behavioral Health
Out-Patient Rehabilitation
Skilled Nursing Facility
Emergency Room Visit $250 co-pay $300 co-pay $250 co-pay
Co-insurance (after deductible) 100% 90% 55%
Individual/Family Deductible $3,000/ $6,000 $1,500/ $3,000 $1,850/ $3,700
Individual/Family Out-of-Pocket Maximum $3,000/ $6,000 $3,500/ $7,000 $6,850/ $13,700
PRESCRIPTION DRUG BENEFITS (after deductible)
Generic Drugs $10 $10 $10
Preferred Brand Drugs $35 $35 $35
Non-Preferred Brand & Specialty Drugs $60 $60 $60
OUT-OF-NETWORK BENEFITS
Co-insurance (after deductible) 60% 60% 30%
Individual/Family Deductible $5,000/ $10,000 $5,000/ $10,000 $10,000/ $20,000
Individual/Family Out-of-Pocket Maximum $10,000/ $20,000 $10,000/ $20,000 $15,000/ $30,000
- 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