Page 7 - Humano EE Guide 06-20
P. 7
Medical Plan Highlights
Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name Bronze PPO Gold PPO Platinum PPO
Prudent Non- Prudent Non- Prudent Non-
1
1
1
Network Name Buyer Network Buyer Network Buyer Network
Plan Differences
Employee Premiums $ $$ $$$
Out of Pocket Costs $$$ $$ $
Employee Cost Sharing Contribution, Deductible, Contribution, Deductible, Contribution, Deductible,
Copay, Coinsurance Copay, Coinsurance Copay, Coinsurance
Network
- Network Size
- In-Network Benefits ✓ ✓ ✓
- Non-Network Benefits ✓ ✓ ✓
Access to Providers Managed by You Managed by You Managed by You
Health Benefits
Lifetime Max Benefit Unlimited Unlimited Unlimited
Deductible (Cal Year)
- Individual $3,950 $7,900 $0 $2,000 $250 $2,000
- Family $7,900 $15,800 $0 $4,000 $750 $4,000
Out-of-Pocket Maximum
- Individual $8,100 $16,200 $7,000 $14,000 $4,000 $8,000
- Family $16,200 $32,400 $14,000 $28,000 $8,000 $16,000
Coinsurance (You Pay) 50% 50% 30% 50% 10% 50%
Office Visit Copay
- Preventive Care No Charge Ded, 50% No Charge Ded, 50% No Charge Ded, 50%
- PCP Ded, 50% Ded, 50% $20 Copay Ded, 50% $15 Copay Ded, 50%
- Specialist Ded, 50% Ded, 50% $50 Copay Ded, 50% $30 Copay Ded, 50%
- Urgent Care Ded, 50% Ded, 50% $50 Copay Ded, 50% $30 Copay Ded, 50%
- Virtual Visits Ded, 50% Ded, 50% $0-$5 Copay Ded, 50% $0-$5 Copay Ded, 50%
Hospitalization
- Inpatient Ded, 50% Ded, 50% 30% Ded, 50% Ded, 10% Ded, 50%
- Outpatient Surgery Ded, 50% Ded, 50% 30% Ded, 50% Ded, 10% Ded, 50%
Lab and X-Ray
- Diagnostic Ded, 50% Ded, 50% $20-$50 Ded, 50% $15-$30 Ded, 50%
Copay Copay
- Complex Ded, 50% Ded, 50% $100, 30% Ded, 50% Ded, $100, Ded, 50%
10%
Emergency Services Ded, 50% $250 Copay, 30% Ded, $200 Copay, 10%
Chiropractic Ded, 50% Not Covered 50% Not Covered Ded, 50% Not Covered
Max 20 Visits/Year Max 20 Visits/Year Max 20 Visits/Year
Acupuncture Ded, 50% Not Covered $20 Copay Not Covered $15 Copay Not Covered
1 Benefit limits may apply to non-network benefits. See SBC for details.
Employee Benefits 7
