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Plan Type PPO
Office Visit for Primary Doctor
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$35 copay
Office Visit for Specialist $50 copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $1,000
Separate Prescription Drugs Deductible $500 Individual;
Applies to Levels 2, 3, 4
Coinsurance 20% after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $2,000
Does not include deductible
Lifetime Maximum $5 Million per person
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. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam 20% Coinsurance/No Deductible
to $300/Calendar Year Preventive Care Maximum
90 Day Waiting Period
Periodic OB-GYN Exam Exam: 20% Coinsurance/No Deductible to $300/Calendar Year Preventive Care Maximum; 90 Day Waiting Period
Pap Smear: 20% Coinsurance/No Deductible; No Calendar Year Preventive Care Maximum; No Waiting Period
Mammogram: 20% Coinsurance/No Deductible; Limited to 130% of medicare reimbursement rate maximum; No Calendar Year Preventive Care Maximum, No Waiting Period
Well Baby Care Child Health Supervision Services
Birth to age one: 20% Coinsurance/No Deductible to $500 calendar year maximum, no waiting period;
Ages 1-8: 20% Coinsurance/No Deductible to $150 calendar year maximum, no waiting period;
Ages 9-18: 20% Coinsurance/No Deductible to $300 calendar year maximum, 90 day waiting period.
Emergency and Urgent Care
Emergency Room $75 Copay (waived if admitted) plus 20% Coinsurance after deductible
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible $500 Individual;
Applies to Levels 2, 3, 4
Mail Order Prescription Drugs N/A
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 20% Coinsurance after deductible
Outpatient Lab/X-Ray First $200 per cal year at 0% Coinsurance, then 20% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 20% Coinsurance after deductible
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Not Covered
Labor & Delivery Hospital Stay Not Covered
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage 20% Coinsurance after deductible
20 Visits/Calendar Year
(Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
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 01/11/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Summary of Benefits & Coverage (Not available)

The Summary of Benefits & Coverage can be found at healthcare.gov. 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 can be found at healthcare.gov. 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.