CAPABILITY OVERVIEW

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8 Odessa R-VII School District 2017
A you will have
the ability to:
 Find Doctors & Hospitals
 Check Claim Status
 Choose Providers & Estimate
Costs
 Access Rx Calculator
 View Benefits
Medical Plan
Odessa R-VII will continue to offer three medical plans through Humana.
As a reminder:
1) We will no longer off a HMO
2) We recommended that you visi or call 1-800-448-
6262 to see if the provider you are using today is in the Humana Choice
Care Network.
3) If you are on a prescription today, it will be very important that you pay
attention to what tier your prescription falls in, and if it is a specialty
drug, know that that you are responsible for a percentage of your drug
up to maximum indicated.
4) If you or a family member are receiving care from a provider that is not
in the Humana network, we encourage you to complete the Transition
of Care form on pages 24-25.
QHDHP BASE PPO BUY-UP PPO
Deductible
- Individual
- Family
$4,000
$8,000
$3,000
$6,000
$0
$0
Coinsurance 0% 20% 0%
Out of Pocket (OOP) Max
- Individual
- Family
$4,000
$8,000 $6,500
$13,000
$5,000
$10,000
Physician Office Visits
- PCP
- Specialist
Subject to Ded.
Subject to Ded.
$30
$55
$25
$55
Hospital Services
- Inpatient
- Outpatient surgical
Subject to Ded.
Subject to Ded.
Ded. then 20%
Ded. then 20%
$500 per day up to $1,500
$500
Emergency Room
Urgent Care
Subject to Ded.
Subject to Ded.
$150
$100
$350
$100
Prescription Drugs
- Deductible
- Tier 1 Generic
- Tier 2 Preferred
- Tier 3 Non-Preferred
- Tier 4/Specialty
@ Humana Pharmacy
@ network non-Humana Pharmacy
- Mail order
All prescriptions
Subject to Deductible
N/A
$10
$35
$55
25% up to OOP max
35% up to OOP max
$25/$87.50/$137.50/25%
N/A
$10
$35
$55
25% up to OOP max
35% up to OOP max
$25/$87.50/$137.50/25%