00.pdf

110043-00.pdf
Preview of 00
🔗 Source: alliantplans.com
📊 Size: 586 KB
👤 Author: Centers for Medicare & Medicaid Services
⬇️ Downloads: 209

Summary

The SoloCare Gold No Referral HMO HDHP Chiro 1600 plan has a coverage period of 01/01/2024 - 12/31/2024. The overall deductible is $1,600 for individuals and $3,200 for families, with a $500 deductible for prescription drugs (except generic drugs). The out-of-pocket limit is $7,050 for individuals and $14,100 for families. Preventive care, screening, and immunization are covered without cost-sharing before meeting the deductible. The plan uses a provider network, and users will pay less if they use a network provider. There is no referral needed to see a specialist.

The plan's cost-sharing structure includes:
- 20% coinsurance for primary care visits, specialist visits, diagnostic tests, imaging, facility fees, physician/surgeon fees, emergency room care, emergency medical transportation, urgent care, hospital stays, mental health services, and home health care.
- $10 copayment for generic drugs, $25 copayment for preferred brand drugs, $75 copayment for non-preferred brand drugs, and $125 copayment for specialty drugs.
- No charge for preventive care, screening, and immunization.
- Not covered for out-of-network services, except for emergency room care and emergency medical transportation, which have 20% coinsurance.

Description

The SoloCare Gold No Referral HMO HDHP Chiro 1600 plan has a coverage period of 01/01/2024 - 12/31/2024.

Technical Information

  • File Format: PDF
  • File Size: 586 KB
  • Pages: 6
  • Language: EN
  • Author: Centers for Medicare & Medicaid Services
  • Total Downloads: 209
  • Last Updated: 3 weeks ago

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