Medical and Pharmacy Coverage
Ultra Commercial Interiors offers the following
plans through Humana.
Insurance Carrier:
Humana Medical Insurance
Medical Plan:
$4,000 / 80% Copay Plan $5,000 / 60% Base Plan
$2,000 / 80% Copay Plan
In-Network: Office Visit Copay - Primary Care
$40 Copay
$40 Copay
$20 Copay
Office Visit Copay - Specialist Care
$65 Copay
$55 Copay
$70 Copay
Urgent Care Copay
$100 Copay
$100 Copay
$100 Copay
Emergency Room Care
$350 Copay
$350 Copay
60% Coinsurance
Preventative Visit Copay
$0
$0
$0
Diagnostic Testing & Blood Work
$0
$0
60% Coinsurance after deductible
Imaging
80% Coinsurance after deductible
80% Coinsurance after deductible
60% Coinsurance after deductible
Coinsurance
80%
80%
60%
Employee Deductible
$2,000
$4,000
$5,000
Family Deductible
$4,000
$8,000
$10,000
Employee Out-of-Pocket Max
$7,900
$6,500
$7,900
Family Out-of-Pocket Max
$15,800
$13,000
$15,800
Inpatient Hospital
80% Coinsurance after deductible
80% Coinsurance after deductible
60% Coinsurance after deductible
Outpatient Hospital or Facility
80% Coinsurance after deductible
80% Coinsurance after deductible
60% Coinsurance after deductible
Out-of-Network: Coinsurance
60%
60%
60%
Employee Deductible
$6,000
$12,000
$15,000
Family Deductible
$12,000
$24,000
$30,000
Employee Out-of-Pocket Max
$23,700
$19,500
$23,700
Family Out-of-Pocket Max
$47,000
$39,000
$47,400
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$10 Copay
$10 Copay
$10 Copay
Tier 2 - Preferred
$45 Copay
$45 Copay
$40 Copay
Tier 3 - Non-Preferred
$90 Copay
$90 Copay
$70 Copay
Tier 4 - Specialty
25% Coinsurance
25% Coinsurance
25% Coinsurance
Per Pay Period
Employee Only
$59.43 $178.28 $160.45 $279.30
$55.83 $167.05 $150.37 $261.58
$44.65 $133.96 $120.57 $209.88
Employee + Spouse Employee + Child(ren)
Family
4 ULTRA COMMERCIAL INTERIORS, INC. 2023 BENEFITS OVERVIEW
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