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See corresponding Summary of Benefits and Coverage for additional information regarding each plan
4
UNDERSTANDING
YOUR MEDICAL PLAN
2017 Benefit Carrier
Network
In Network
Out of Network
In Network Only
Out of Network
In Network
Out of Network
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Single
$6,300
$18,900
$2,500
$7,500
$5,000
$15,000
Family
$12,600
$37,800
$7,500
$22,500
$10,000
$30,000
Coinsurance
100% BCBS/0%
Insured
50% BCBS/50%
Insured
80% BCBS/20%
Insured
50% BCBS/50%
Insured
100% BCBS/0%
Insured
50% BCBS/50%
Insured
Single
$6,550
$19,650
$7,150
$21,450
$7,150
$21,450
Family
$13,100
$39,300
$14,300
$42,900
$14,300
$42,900
PCP
Member pays 0%
after DED
Member pays 50%
after DED
$25 Copay
Member pays 50%
after DED
$25 Copay
Member pays 50%
after DED
Specialist
Member pays 0%
after DED
Member pays 50%
after DED
$50 Copay
Member pays 50%
after DED
$50 Copay
Member pays 50%
after DED
Advanced Imaging (MRI, CT Scans etc)
Member pays 0%
after DED
Member pays 50%
after DED
Member pays 20%
after DED
Member pays 50%
after DED
Member pays 0%
after DED
Member pays 50%
after DED
Urgent Care
Member pays 0%
after DED
Member pays 50%
after DED
$60 Copay
Member pays 50%
after DED
$60 Copay
Member pays 50%
after DED
Emergency Room
Member pays 0%
after DED
Member pays 50%
after DED
$150, then 20% $150, then 20% $150 Copay
$150 Copay
Preventive Care Services
Member pays 0%
after DED
Member pays 50%
after DED
Member pays 0%
Member pays 50%
after DED
Member pays 0%
Member pays 50%
after DED
Outpatient Services
Member pays 0%
after DED
Member pays 50%
after DED
Member pays 20%
after DED
Member pays 50%
after DED
Member pays 0%
after DED
Member pays 50%
after DED
Hospital Services
Member pays 0%
after DED
Member pays 50%
after DED
Member pays 20%
after DED
Member pays 50%
after DED
Member pays 0%
after DED
Member pays 50%
after DED
$200 Rx DED
(Tier 2, 3, & 4 only)
▪ Retail Drugs - Tier 1 (30 day supply)
Member pays 0%
after DED
$15 copayment
$15 copayment
▪ Retail Drugs - Tier 2 (30 day supply)
Member pays 0%
after DED
$45 copayment
$35 copayment
▪ Retail Drugs - Tier 3 (30 day supply)
Member pays 0%
after DED
$85 copayment
$60 copayment
▪ Retail Drugs - Tier 4 (Specialty Drugs)
(30 day supply)
Member pays 0%
after DED
Member pays 20%,
up to a $300 max per
fill
Member pays 20%,
up to a $300 max
per fill
POS $5000 100%
PLAN 1
PLAN 3
Blue Cross Blue Shield of GA
Blue Cross Blue Shield of GA
Blue Open Access POS
Blue Open Access POS
PLAN 2
Blue Cross Blue Shield of GA
Blue Open Access POS
POS $2500 80%
POS HDHP $6300 100%
MAIL ORDER IS AVAILABLE
Physican Office Visit
Calendar Year Out of Pocket Maximum
Calendar Year Deductible
As we all know, the cost of quality health coverage has increased over the past few years. At the same time,
we need health care that protects our physical health as much as health care that protects our financial
wellbeing. That’s why Exceptional Restaurants believes it is important to invest in quality plans that are cost
effective, easy to use and valuable to you. Exceptional Restaurant provides the following options with Humana.
Please contact your Human Resources Department for bi-weekly payroll deduction information.