Medical and Pharmacy Coverage
Page, Scrantom offers the following plans through Humana. Please reference the Summary Plan Description for more details.
Insurance Carrier: Medical Plan Number:
Humana Medical Insurance
80 / 60 NPOS BUY-UP OPT 43 80 / 60 NPOS OPT 44 90 / 60 NPOS-HDHP
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$40 Copay $55 Copay $100 Copay $350 Copay
$40 Copay $65 Copay $100 Copay $350 Copay
10% Coinsurance 10% Coinsurance 10% Coinsurance 10% Coinsurance
Urgent Care Copay
Emergency Room Care
Preventative Visit Copay
$0 $0
$0 $0
$0
Diagnostic Testing & Blood Work
10% Coinsurance 10% Coinsurance
Imaging
20% Coinsurance
20% Coinsurance
Coinsurance
20%
20%
10%
Employee Deductible
$2,000 $4,000 $5,000 $10,000
$2,000 $4,000 $6,500 $13,000
$5,000
Family Deductible
$10,000
Employee Out-of-Pocket Max
$6,350
Family Out-of-Pocket Max
$12,700
Inpatient Hospital
20% Coinsurance
20% Coinsurance
10% Coinsurance 10% Coinsurance
Outpatient Hospital or Facility
$40 Copay
$40 Copay
Out-of-Network: Coinsurance
30%
30%
40%
Employee Deductible
$6,000
$6,000
$15,000 $30,000 $19,050 $38,100
Family Deductible
$12,000 $15,000 $30,000
$12,000 $19,500 $39,000
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$0
$0
Medical Deductible Applies
Tier 1 - Generic
$10 Copay $40 Copay $70 Copay
$10 Copay $45 Copay $90 Copay
10% Coinsurance 10% Coinsurance 10% Coinsurance 10% Coinsurance
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
35% Coinsurance
35% Coinsurance
Employee Bi-Weekly Deduction Employee Only
$23.40 $323.13 $278.17 $577.90
$14.57 $305.88 $262.19 $494.39
$0.00
Employee + Spouse Employee + Child(ren)
$133.84 $103.04 $308.34
Family
5 Page, Scrantom 2022 Enrollment Guide
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