CAPABILITY OVERVIEW

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7 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 offers three medical plans through Humana for you to choose from.
We recommended that you visi or call 1-800-448-6262
to see if your provider is in the Humana Choice Care Network.
The Medical Plan chart below is for illustrative purposes only and does not
include all benefits, plan limitations, and/or exclusions. This represents in-
network benefits only. Please refer to the Humana summary for greater
detail. In the event there is a discrepancy in benefits, the carrier benefit
summary/SPD will always govern.
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%