SoloCare PPO Gold Standardized

83761GA0040378
Gold
PPO

SoloCare PPO Gold Standardized is a Gold PPO plan by Alliant Health Plans.

IMPORTANT: You are viewing the 2023 version of SoloCare PPO Gold Standardized 83761GA0040378. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

SoloCare PPO Gold Standardized is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of SoloCare PPO Gold Standardized 83761GA0040378.
Insurer: Alliant Health Plans
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 83761GA0040378

Cost-Sharing Overview

SoloCare PPO Gold Standardized offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for SoloCare PPO Gold Standardized?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

SoloCare PPO Gold Standardized offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Diabetes
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what SoloCare PPO Gold Standardized covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Coverage is available for emergency situations
Out of Service Area Coverage: No
Out of Service Area Coverage Description: In-Network providers available in certain Tennessee counties that border Georgia. Verify participating providers at AlliantPlans.com
National Network: No

Additional Benefits and Cost-Sharing

SoloCare PPO Gold Standardized includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 40.00% Coinsurance after deductible
Specialist Visit
Covered
$60.00 40.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 40.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Hospice care covered expenses do not include: A confinement not required for acute pain control or other treatment for an acute phase of chronic symptom management.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 40.00% Coinsurance after deductible
Home Health Care Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible120 Visit(s) per Year Covered services for Home Health do not include: Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care Services which are not Medically Necessary or of a non-skilled level of care. Services of a person who ordinarily resides in the patient’s home or is a member of the family of either the patient or the patient’s spouse. Any services for any period during with the Member is not under the continuing care of a PHysician, Convalescent or Custodial Care where the Member has spent a period of time recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. Any services or supplies not specifically listed as Covered Services. Routine care and/or examination of a newborn child. Dietician services. Maintenance therapy. Dialysis treatment. Purchase or rental of dialysis equipment. Private duty nursing care. Medical treatment provided in the home on a part time or intermittent basis including visits by a licensed health care professional, including a nurse, therpaist, or home health aide; and physical speech, and occupational therapy. When these therapy services are provided as part of home health they are not subject to separate visit limits for therapy services.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible60 Days per Year Beneifts will not be provided when: A Member reaches the maximum level of recovery possible and no longer requires other than routine care; Care is primarily Custodial Care, not requiring definitive medical or 24-hour-a-day nursing service; Care is for chronic brain syndromes for which no specific medical conditions exist that require care in a Skilled Nursing Faciliy; A Member is undergoing senile deterioration, mental deficiency or retardation, and has no medical condition requiring care; The care rendered is for other than Skilled Convalescent Care.
Prenatal and Postnatal Care
Covered
$30.00 40.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$30.00 40.00% Coinsurance after deductible Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$30.00 40.00% Coinsurance after deductible Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Generic Drugs
Covered
$15.00 $15.00 Excludes infertility services including medications.
Preferred Brand Drugs
Covered
$30.00 $30.00 Excludes infertility services including medications.
Non-Preferred Brand Drugs
Covered
$60.00 $60.00 Excludes infertility services including medications.
Specialty Drugs
Covered
$250.00 $250.00 Excludes infertility services including medications.
Outpatient Rehabilitation Services
Covered
$30.00 40.00% Coinsurance after deductible40 Visit(s) per Year Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help – Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.
Habilitation Services
Covered
$30.00 40.00% Coinsurance after deductible40 Visit(s) per Year Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help – Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing. Habilitation is classified the same as Rehabilitation under medical/surgical benefits not mental health/substance abuse.
Chiropractic Care
Not Covered
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 40.00% Coinsurance after deductible The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible4 Visit(s) per Year
Routine Eye Exam for Children
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible1 Exam(s) per Year
Eye Glasses for Children
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible1 Item(s) per Year
Dental Check-Up for Children
Not Covered
2 Procedure(s) per Year
Rehabilitative Speech Therapy
Covered
$30.00 40.00% Coinsurance after deductible40 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 40.00% Coinsurance after deductible40 Visit(s) per Year
Well Baby Visits and Care
Covered
0.00% 40.00% Coinsurance after deductible Care provided for birth through age 5.
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible10000 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant.
Accidental Dental
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Dialysis
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Allergy Testing
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Chemotherapy
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Diabetes Education
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Infusion Therapy
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible Insulin infusion devices.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Nutritional Counseling
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible4 Visit(s) per Year
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 40.00% Coinsurance after deductible AHP will cover Gender-Affirming Care that is deemed medically necessary through a review of clinical documentation provided as part of our utilization management processes

Free Preventive Services

There is no copayment or coinsurance for any of the following SoloCare PPO Gold Standardized preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for SoloCare PPO Gold Standardized including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for SoloCare PPO Gold Standardized?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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