Page 5 - Humano Employee Benefit Guide 2019

Benefits

Medical Insurance

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

2
2
2
Network Name Network Non-Network Network Non-Network Network Non-Network
Health Benefits
Deductible (Annual)
- Individual $4,600 $9,200 None $2,000 $250 $2,000
- Family $9,200 $18,400 None $4,000 $750 $4,000
Co-Insurance (You Pay) 40% 50% 30% 50% 10% 50%

Office Visit Copay
1
- Primary Care Physician $65 Copay Ded, 50% $20 Copay Ded, 50% $15 Copay Ded, 50%
1
- Specialist Office Visit $85 Copay Ded, 50% $50 Copay Ded, 50% $30 Copay Ded, 50%
Out-of-Pocket Maximum
- Individual $7,900 $15,800 $6,500 $13,000 $3,800 $7,600
- Family $15,800 $31,600 $13,000 $26,000 $7,600 $15,200

Hospitalization
- Inpatient Ded, 40% Ded, 50% Ded, 30% Ded, 50% Ded, 10% Ded, 50%
- Outpatient Ded, 40% Ded, 50% Ded, 30% Ded, 50% Ded, 10% Ded, 50%
Lab and X-Ray Ded, 40% Ded, 50% Ded, 30% Ded, 50% Ded, 10% Ded, 50%
(Ded, $100 (Ded, $100
Copay, 30% Copay, 10%
Advanced) Advanced)
Emergency Services Ded, 50% Ded, $250 Copay, 30% Ded, $200 Copay, 10%
Urgent Care Ded, 40% Ded, 50% $50 Copay Ded, 50% $30 Copay Ded, 50%

Preventive Care 100% Ded, 50% 100% Ded, 50% 100% Ded, 50%
Pharmacy Benefits

Pharmacy Deductible Applies to Tier 2 & 3: Applies to Tier 2 & 3:
- Individual Medical Ded $250 None
- Family $500 None

Retail Pharmacy
- Tier 1 $10/$20 Copay Not Covered $5/$20 Copay Not Covered $5/$15 Copay Not Covered
- Tier 2 $60 Copay Not Covered $40 Copay Not Covered $35 Copay Not Covered
- Tier 3 $90 Copay Not Covered $80 Copay Not Covered $70 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A 30 Days N/A
Mail Order Pharmacy
- Tier 1 $25/$50 Copay Not Covered $13/$50 Copay Not Covered $13/$38 Copay Not Covered
- Tier 2 $180 Copay Not Covered $120 Copay Not Covered $105 Copay Not Covered
- Tier 3 $270 Copay Not Covered $240 Copay Not Covered $210 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A 90 Days N/A

1
Deductible waived for the first 3 non-preventive visits
2
Benefit limits apply
5