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BrightHouse, a division of BCG
Plan Highlights
12/01/2017– 11/30/2018 Plan Year
Medical
HUMANA -
NATIONAL POS OA 100/70 Group #576817
DEDUCTIBLE:
$1,000 per individual/$2,000 per family, per calendar year, for in-network benefits.
$3,000 per individual/$6,000 per family, per calendar year, for out-of-network benefits.
COINSURANCE:
Humana pays 100% per individual for in-network benefits.
Humana pays 70% per individual, following the deductible, for out-of-network benefits.
Upon meeting the out-of-pocket maximum, reimbursement is 100% of covered charges.
The benefit percentage is based upon the use of physicians and hospitals listed as
participating in the Humana National POS Open Access network.
COPAY:
$25 Copay will apply to in-network physician office visit charges. $40 Specialist Copay.
PREVENTIVE CARE:
Covered at 100%
ER COPAY:
$400 (In and Out of Network) copay waived if admitted into the hospital
OUT-OF-POCKET:
$ 4,000 per individual/$ 8,000 per family, per calendar year, for in-network (including deductible)
$12,000 per individual/$24,000 per family, per cal. year, for out-of-network (including deductible)
PRESCRIPTION DRUGS:
Retail/30 Day Supply: $10 Copay Level 1; $30 Copay Level 2; $50 Copay Level 3; 25% Level 4
90 Day Supply via Mail Order:
1.5 times the retail copay Level 1; 2.5 times the retail copay Level 2; 3 times the retail copay
Level 3
WEBSITE:
www.humana.com(Humana National POS - Open Access)
Dental
GUARDIAN
DEDUCTIBLE:
$50 per individual ($150 per family) per calendar year
PREVENTIVE CARE:
Covered at 100% (Deductible is Waived)
BASIC CARE:
Covered at 100% (When choosing the Value Plan)
Covered at 80% (When choosing the NAP Plan)
MAJOR CARE:
Covered at 60% (When choosing the Value Plan)
Covered at 50% (When choosing the NAP Plan)
ANNUAL MAXIMUM:
$2000 per calendar year
ORTHODONTIC CARE:
Child Orthodontia. Plan pays 50% (no deductible) of the covered orthodontia services,
up to $2,000 lifetime orthodontia maximum
ADDITIONAL BENEFITS:
Rollover benefit; College Tuition Benefit Services
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