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Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
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No Charge
Office Visit for Specialist No Charge
Office Visit for Other Practitioner (Nurse, Physician Assistant) No Charge
Annual Deductible None
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 0%
Retail Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Off Label Prescription Drugs: No Charge
Annual Out-of-Pocket Limit $0
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage Yes. Out of Country Coverage is covered for any expense incurred for services received outside of the United States as required by law for emergency care services. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room No Charge
Emergency Ambulance Services No Charge
Urgent Care Facility No Charge
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Off Label Prescription Drugs: No Charge
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Off Label Prescription Drugs: No Charge
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery No Charge
Outpatient Lab/X-Ray No Charge
Imaging (CT and PET scans, MRIs) No Charge
Outpatient Mental Health No Charge
Outpatient Substance Abuse No Charge
Outpatient Rehabilitation Services (PT, OT, ST) No Charge, Rehabilitative Speech Therapy 30 visits per year. Rehabilitative Occupational and Rehabilitative Physical Therapy 30 visits per year.
Inpatient Coverage
Hospitalization No Charge
Skilled Nursing Facility No Charge, 45 Days per Year
Inpatient Mental Health No Charge
Inpatient Substance Abuse No Charge
Home Healthcare No Charge, 45 Days per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay No Charge
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge, 1 Visit(s) per Year
Eye Glasses for Children No Charge, 1 Item(s) per Year; 1 pair of lenses every year, 1 frame every 2 years
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage No Charge, 30 Visit(s) per Year
Durable Medical Equipment No Charge
Hospice No Charge, 45 Days per Year
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) No Charge, 1 Treatment(s) per Year
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A- as of 02/28/2014
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Customer reviews

Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Humana - Insured by Humana Insurance Company, Humana Health Plan, Inc., Humana Health Insurance Company of Florida, Inc., or Humana Health Benefit Plan of Louisiana, Inc., Or offered by Humana Medical Plan Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan of Texas, Inc. ,Humana Health Plan, Inc. , Humana Medical Plan of Michigan, In,. ,Humana Health Plan of Ohio, Inc., or Humana Medical Plan of Utah, Inc.
  • Humana - For Arizona residents: Insured by Humana Insurance Company or offered by Humana Health Plan, Inc.. For Texas residents: Insured by Humana Insurance Company or offered by Humana Health Plan of Texas, Inc.
  • Humana - Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, call or write your Humana insurance agent or broker.
  • Humana - Insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of Kentucky, Humana Health Insurance Company of Florida, Inc., Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., CompBenefits Direct, Inc., Humana Health Benefit Plan of Louisiana, Inc., DentiCare, Inc. (d/b/a CompBenefits), or Texas Dental Plans, Inc.