Medical Benefits
Find a doctor at www.humana.com // Network: Humana/ChoiceCare Network PPO
In-Network |
Out-of-Network |
|
---|---|---|
Deductible |
$1,000/$2,000 |
$2,000/$4,000 |
Member Coinsurance |
20% |
50% |
Out-of-Pocket Max |
$4,000/$8,000 |
$12,000/$24,000 |
Physician Office Visit |
$25 Copay |
Deductible + 30% |
Preventive Care |
Covered at 100% |
Deductible + 30% |
Doctor on Demand Telemedicine |
$25 Copay |
Deductible + 30% |
Specialist Visit |
$50 Copay |
Deductible + 30% |
Inpatient Hospital |
Deductible + 20% |
Deductible + 50% |
Outpatient Hospital |
Deductible + 20% |
Deductible + 20% |
Ambulance—Ground or Air |
Deductible + 20% |
Deductible + 20% |
Urgent Care |
$100 Copay |
Deductible + 50% |
Emergency Room |
$400 Copay |
$400 Copay |
Mental Health Services: |
$25 Copay/Visit |
Deductible + 30% |
Prescription Drugs |
In-Network |
Out-of-Network |
---|---|---|
Retail |
||
Tier 1 |
$10 Copay |
Retail Copay + 30% |
Tier 2 |
$30 Copay |
Retail Copay + 30% |
Tier 3 |
$50 Copay |
Retail Copay + 30% |
Tier 4 |
25% Coinsurance |
Retail Copay + 30% |
Specialty |
35% Coinsurance (Retail) |
50% Coinsurance |
Mail Order Drugs |
||
Level 1 |
$25 Copay |
Retail Copay + 30% |
Level 2 |
$75 Copay |
Retail Copay + 30% |
Level 3 |
$125 Copay |
Retail Copay + 30% |
Level 4 |
25% Coinsurance |
Retail Copay + 30% |
Bi-Weekly Employee Rates |
|
---|---|
Employee Only |
$147.69 |
Employee + Spouse |
$411.92 |
Employee + Child(ren) |
$330.70 |
Employee + Family |
$632.10 |
Find a doctor at www.humana.com // Network: Humana/ChoiceCare Network PPO
In-Network |
Out-of-Network |
|
---|---|---|
Deductible |
$3,000/$6,000 |
$6,000/$12,000 |
Member Coinsurance |
20% |
50% |
Out-of-Pocket Max |
$6,500/$13,000 |
$19,500/$35,000 |
Physician Office Visit |
$35 Copay |
Deductible + 50% |
Preventive |
Covered at 100% |
Deductible + 50% |
Specialist Visit |
$60 Copay |
Deductible + 50% |
Doctor on Demand Telemedicine |
$35 Copay |
Deductible + 30% |
Inpatient Hospital |
Deductible + 20% |
Deductible + 50% |
Outpatient Hospital |
Deductible + 20% |
Deductible + 50% |
Ambulance—Ground or Air |
Deductible + 20% |
Deductible + 20% |
Urgent Care |
$100 Copay |
Deductible + 50% |
Emergency Room |
$350 Copay |
$350 Copay |
Mental Health Services: |
$35 Copay/Visit |
Deductible + 30% |
Prescription Drugs |
||
---|---|---|
Retail |
||
Tier 1 |
$10 Copay |
Retail Copay + 30% |
Tier 2 |
$45 Copay |
Retail Copay + 30% |
Tier 3 |
$90 Copay |
Retail Copay + 30% |
Tier 4 |
25% Coinsurance |
Retail Copay + 30% |
Specialty |
35% Coinsurance (Retail) |
50% Coinsurance |
Mail Order |
||
Tier 1 |
$25 Copay |
Retail Copay + 30% |
Tier 2 |
$112.50 Copay |
Retail Copay + 30% |
Tier 3 |
$225 Copay |
Retail Copay + 30% |
Tier 4 |
25% Coinsurance |
Retail Copay + 30% |
Specialty |
N/A |
N/A |
Bi-Weekly Employee Rates |
|
---|---|
Employee Only |
$95.54 |
Employee + Spouse |
$307.63 |
Employee + Child(ren) |
$231.62 |
Employee + Family |
$465.24 |