Humana Insurance Company Autograph Total/5200 HSA Georgia Health Insurance Plan Details

	Autograph Total/5200 HSA

Overview

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
0% Coinsurance after deductible
Office Visit for Specialist
0% Coinsurance after deductible
Coinsurance
0% after deductible
Separate Prescription Drugs Deductible
None
Prescription Drugs
Discount Card Included
This added value feature is not insurance
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Emergency Care Only. Paid as out-of-network, and member must submit an itemized bill with services rendered and a diagnosis in order to be reimbursed.

Periodic Health Exam
0% Coinsurance/No Deductible
to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
Periodic OB-GYN Exam
Exam: 0% Coinsurance/ No Deductible to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
Pap Smear/Mammogram: 0% Coinsurance/ No Deductible; No Preventive Care Maximum; No Waiting Period
Well Baby Care
Child Wellness - Birth to age 5: 0% Coinsurance/ No Deductible; No Calendar Year Preventive Care Maximum; No Waiting Period;
Routine Immunizations (age 6 to 18): 0% Coinsurance/No Deductible
to $300/Calendar Year Preventive Care Maximum; No Waiting Period.