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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.
MEDICAL BENEFITS / cost effective peace of mind
Page 2
PLAN 2
2016 Benefit Carrier
Network
Blue Open Access
HMO
HMO $2500 80%
In Network
Out of Network
In Network Only
In Network
Out of Network
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Calendar Year Deductible
Single
$5,000
$10,000
$2,500
$5,000
$10,000
Family
$10,000
$20,000
$7,500
$10,000
$20,000
Coinsurance
80% BCBS/20%
Insured
60% BCBS/40%
Insured
80% BCBS/20%
Insured
100% BCBS/0%
Insured
70% BCBS/30%
Insured
Calendar Year Out of Pocket
Maximum
Single
$6,450
$19,350
$6,600
$5,000
$15,000
Family
$12,900
$38,700
$13,200
$10,000
$30,000
Physican Office Visit
PCP
DED, then $30
Member pays 40%
after DED
$25 Copay
$25 Copay
Member pays 30%
after DED
Specialist
DED, then $60
Member pays 40%
after DED
$50 Copay
$50 Copay
Member pays 30%
after DED
Advanced Imaging
(MRI, CT Scans etc)
Member pays 20%
after DED
Member pays 40%
after DED
Member pays 20%
after DED
Member pays 0%
after DED
Member pays 30%
after DED
Urgent Care
DED/COIN, then $60
Member pays 40%
after DED
$60 Copay
$60 Copay
Member pays 30%
after DED
Emergency Room
Member pays 20%
after DED
Member pays 20%
after DED
$150, then 20%
$150 Copay
$150 Copay
Preventive Care Services
Member pays 0%
Member pays 30%
after DED
Member pays 0%
Member pays 0%
Member pays 30%
after DED
Outpatient Services
Member pays 20%
after DED
Member pays 40%
after DED
Member pays 20%
after DED
Member pays 0%
after DED
Member pays 30%
after DED
Hospital Services
Member pays 20%
after DED
Member pays 40%
after DED
Member pays 20%
after DED
Member pays 0%
after DED
Member pays 30%
after DED
Retail Drugs - Tier 1
(30 day supply)
$15 after deductible
$15 copayment
$15 copayment
Retail Drugs - Tier 2
(30 day supply)
$40 after deductible
$35 copayment
$35 copayment
Retail Drugs - Tier 3
(30 day supply)
$80 after deductible
$60 copayment
$60 copayment
Retail Drugs - Tier 4
(Specialty Drugs) (30 day supply)
Member pays 25%
after deductible per
Script Max $350
Member pays 20%, up
to a $300 max per fill
Member pays 20%, up
to a $300 max per fill
MAIL ORDER IS AVAILABLE
*See corresponding Summary of Benefits and Coverage for additional information regarding each plan
POS HDHP $5000 80%
POS $5000 100%
PLAN 1
PLAN 3
Blue Open Access POS
Blue Open Access POS
Blue Cross Blue Shield of GA