Humana Insurance Company Autograph Share 80/5000 Plus Rx & Doctor Visit Copay Kansas Health Insurance Plan Details

	Autograph Share 80/5000 Plus Rx & Doctor Visit Copay

Overview

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
First 6 visits (combined Primary and Specialist). $35 copay, thereafter subject to deductible & 20% coinsurance.
Office Visit for Specialist
First 6 visits (combined Primary and Specialist). $50 copay, thereafter subject to deductible & 20% coinsurance.
Coinsurance
20% after deductible
Separate Prescription Drugs Deductible
$1,000 Individual
Applies to Levels 2, 3, 4
Prescription Drugs
Rx Deductible for Levels 2, 3, 4
Level 1: $15 copay
Level 2: $35 copay
Level 3: $55 copay
Level 4: 25% copay up to $2500 maximum out of pocket.
Levels based on specific drug
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
20% Coinsurance/No Deductible;
To $300/Calendar Year Preventive Care Maximum; No Waiting Period
Periodic OB-GYN Exam
Exam: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum; No Waiting Period
Pap Smear/Mammogram: 20% Coinsurance/ No Deductible; No Preventive Care Maximum; No Waiting Period
Well Baby Care
Immunization - birth to 72 months: 0% Coinsurance/No Deductible, No Preventive Care Maximum, No Waiting Period;
Other services: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum. No Waiting Period

Emergency Room
$75 Copay (waived if admitted) plus 20% Coinsurance after deductible
Outpatient Lab/X-Ray
First $200 per cal year at 0% Coinsurance, then 20% Coinsurance after deductible
Outpatient Surgery
20% Coinsurance after deductible
Hospitalization
20% Coinsurance after deductible

Chiropractic Coverage
20% Coinsurance after deductible
20 Visits/Calendar Year
(Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Mental Health Coverage
Outpatient: 0% Coinsurance/No Deductible of first $100; 20% Coinsurance/No Deductible of the next $100; 50% Coinsurance/No Deductible of the next $1640/Calendar Year, $7500 Outpatient Lifetime Maximum, No Waiting Period.