2020-2021 Benefits Guide rev 6.22.2021

MEDICAL PLAN SUMMARY COMPARISON CHART The table below reflects an overview of some of the more common services used.

Humana NPOS

Humana HDHP

Services you may need

IN-NETWORK

OUT-OF- NETWORK

IN-NETWORK

OUT-OF-NETWORK

Calendar Year Deductible Individual RX Out-of-Pocket Limit: Individual Family Out-of-Pocket Limit Individual Family

$5,000 $10,000

$15,000 $30,000

$6,350 $12,700

$19,050 $38,100

Embedded with Medical Out-of-Pocket Limit (excludes non-network RX)

Embedded with Medical Out-of-Pocket Limit (excludes non-network RX)

$6,500 $13,000

$19,500 $39,000

$6,350 $12,700

$21,550 $43,100

Family

Office Visits

Primary Care Physician

$35 copay $50 copay $35 copay

100% after cal yr deductible

Specialist

50% coinsurance

30% coinsurance

Virtual Visit

Preventative care Preventive Care/Screening Immunizations Diagnostic Testing

No charge; deductible does not apply

No charge; deductible does not apply

50% coinsurance

30% coinsurance

(Routine Physicals)

No charge; deductible does not apply

100% after cal yr deductible

X-ray / Blood work

50% coinsurance

30% coinsurance

30% coinsurance after cal yr deductible

Imaging (CT/PET scans, MRIs)

100% after cal yr deductible

20% coinsurance

50% coinsurance

Immediate Medical Attention

$100 copay; deductible does not apply $350 copay; deductible does not apply

30% coinsurance after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 30% coinsurance after cal yr deductible

100% after cal yr deductible

Urgent Care

50% coinsurance

Emergency Room Care (copay waived if admitted) Emergency Transport

$350 copay; deductible does not apply

100% after cal yr deductible 100% after cal yr deductible

20% coinsurance

20% coinsurance

Hospitalization Facility fee

20% coinsurance 20% coinsurance

50% coinsurance 50% coinsurance

100% after cal yr deductible

Physician/surgery fees

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