SoloCare Platinum No Referral HMO – $0 PCP, $0 Generic Rx – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$750 per person $750 per person
Out-of-pocket max	$1,500 per person $3,000 per family
Metal tier	Platinum

Visit Copay

Primary care visit	No charge
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	Share
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	No charge

Mental and Psychiatric Health Care

Mental Health outpatient services	No charge
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://alliantplans.com/doc/2024/solocare/110028-01.pdf
Drug and medication plan formulary	https://magellan.adaptiverx.com/webSearch/index?key=cnhmbGV4LnBsYW4uUGxhblBkZlR5cGUtOTE3
Search doctor list	https://idirectory.alliantplans.com/ProviderSearch