Page 5 - Humano Employee Benefit Guide 2018

Benefits

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Bronze PPO Platinum PPO

Network Name Blue Cross PPO Non-Network Blue Cross PPO Non-Network
(Prudent Buyer) - (Prudent Buyer) -
Small Group Network Small Group Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $5,000 $10,000 $200 $400
- Family $10,000 $20,000 $600 $800

Co-Insurance (You Pay) 30% 50% 10% 50%
Office Visit Copay
- Primary Care Physician $30 Copay* Deductible, 50% $10 Copay Deductible, 50%
- Specialist Office Visit $30 Copay* Deductible, 50% $30 Copay Deductible, 50%
Out-of-Pocket Maximum
- Individual $7,350 $14,700 $3,000 $6,000
- Family $14,700 $29,400 $6,000 $12,000

Hospitalization
- Inpatient Deductible, $500 Copay Deductible, 50% Deductible, 10% Deductible, 50%
- Outpatient Deductible, $300 Deductible, 50% Deductible, 10% Deductible, 50%
Copay, 30%
Lab and X-Ray Deductible, 30% Deductible, 50% Deductible, 10% Deductible, 50%

Emergency Services Deductible, 30% Deductible, $200 Copay, 10%
Urgent Care Deductible, 30% Deductible, 50% $20 Copay Deductible, 50%
Preventive Care 100% Deductible, 50% 100% Deductible, 50%
Pharmacy Benefits

Pharmacy Deductible
- Individual $1,000 N/A None N/A
- Family $2,000 N/A None N/A
Retail Pharmacy
- Generic Formulary $5 / $20 Copay Not Covered $5 / $15 Copay Not Covered
- Brand Name Formulary $60 Copay Not Covered $35 Copay Not Covered
- Non-Formulary $100 Copay Not Covered $70 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A

Mail Order Pharmacy
- Generic Formulary $13 / $50 Copay Not Covered $13 / $38 Copay Not Covered
- Brand Name Formulary $180 Copay Not Covered $105 Copay Not Covered
- Non-Formulary $300 Copay Not Covered $210 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

*Office visits are covered at the indicated Copay for the first 3 non-preventive visits, then the deductible and coinsurance will apply

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