SoloCare PPO Silver Standardized
83761GA0040379
Silver
PPO
SoloCare PPO Silver Standardized is a Silver PPO plan by Alliant Health Plans.
IMPORTANT: You are viewing the 2023 version of SoloCare PPO Silver Standardized 83761GA0040379. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
SoloCare PPO Silver Standardized is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of SoloCare PPO Silver Standardized 83761GA0040379.
| Insurer: | Alliant Health Plans |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 83761GA0040379 |
Cost-Sharing Overview
SoloCare PPO Silver Standardized offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for SoloCare PPO Silver Standardized includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
| Deductible: | $5,800.00 | $5800 per person | $11600 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for SoloCare PPO Silver Standardized will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $20,000.00 | $20000 per person | $40000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,800.00 |
| Copayment: | $50.00 |
| Coinsurance: | $1,700.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $1,100.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $1,700.00 |
| Copayment: | $400.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 Silver 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 Silver 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 Silver 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 Silver 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 | $40.00 | 40.00% Coinsurance after deductible | |
| Specialist Visit Covered | $80.00 | 40.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 40.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Hospice Services Covered | 40.00% 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 | $60.00 | 40.00% Coinsurance after deductible | |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 120 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Skilled Nursing Facility Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 60 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 | $40.00 | 40.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Generic Drugs Covered | $20.00 | $20.00 | Excludes infertility services including medications. |
| Preferred Brand Drugs Covered | $40.00 | $40.00 | Excludes infertility services including medications. |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible | $80.00 Copay after deductible | Excludes infertility services including medications. |
| Specialty Drugs Covered | $350.00 Copay after deductible | $350.00 Copay after deductible | Excludes infertility services including medications. |
| Outpatient Rehabilitation Services Covered | $40.00 | 40.00% Coinsurance after deductible | 40 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 | $40.00 | 40.00% Coinsurance after deductible | 40 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | 40.00% 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 4 Visit(s) per Year |
| Routine Eye Exam for Children Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 1 Item(s) per Year |
| Dental Check-Up for Children Not Covered | 2 Procedure(s) per Year | ||
| Rehabilitative Speech Therapy Covered | $40.00 | 40.00% Coinsurance after deductible | 40 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 | 40.00% Coinsurance after deductible | 40 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | 40.00% 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 10000 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
| Accidental Dental Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Dialysis Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Allergy Testing Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Radiation Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Diabetes Education Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | Insulin infusion devices. |
| Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Nutritional Counseling Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | 4 Visit(s) per Year |
| Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Gender Affirming Care Covered | 40.00% 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 Silver 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for SoloCare PPO Silver 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 Silver 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