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Plan Type PPO
Metal Level Gold
Office Visit for Primary Doctor
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$25
Office Visit for Specialist $35
Office Visit for Other Practitioner (Nurse, Physician Assistant) $25
Annual Deductible Individual: $2,500
Separate Prescription Drugs Deductible Individual: $500; Family: $1,000. Applies to all drugs except generic drugs.
Coinsurance 20%
Retail Prescription Drugs Preferred Generic Drugs: $5 copay; Non-Preferred Generic Drugs: $10 copay; Preferred Brand Name Drugs: $20 copay after deductible; Non-Preferred Brand Name Drugs: 35% coinsurance after deductible; Specialty Drugs: 35% coinsurance after deductible.
Annual Out-of-Pocket Limit Individual: $3,500
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
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 No
Specialist Referrals Required No
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 20% Coinsurance after deductible
Emergency Ambulance Services 20% Coinsurance after deductible
Urgent Care Facility $50
Prescription Drug Coverage
Retail Prescription Drugs Preferred Generic Drugs: $5 copay; Non-Preferred Generic Drugs: $10 copay; Preferred Brand Name Drugs: $20 copay after deductible; Non-Preferred Brand Name Drugs: 35% coinsurance after deductible; Specialty Drugs: 35% coinsurance after deductible.
Separate Prescription Drugs Deductible Individual: $500; Family: $1,000. Applies to all drugs except generic drugs.
Mail Order Prescription Drugs Preferred Generic Drugs: $10 copay; Non-Preferred Generic Drugs: $20 copay; Preferred Brand Name Drugs: $40 copay after deductible; Non-Preferred Brand Name Drugs: 35% coinsurance after deductible; Specialty Drugs: 35% coinsurance after deductible.
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 20% Coinsurance after deductible
Outpatient Lab/X-Ray First $500 per calendar year at no charge, then 20% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 20% Coinsurance after deductible
Outpatient Mental Health 20% Coinsurance after deductible
Outpatient Substance Abuse 20% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 20% Coinsurance after deductible.Rehabilitative Occupational Therapy 20 visits per year. Rehabilitative Physical Therapy 20 visits per year.
Inpatient Coverage
Hospitalization 20% Coinsurance after deductible
Skilled Nursing Facility 20% Coinsurance after deductible, 60 Days per Year
Inpatient Mental Health 20% Coinsurance after deductible
Inpatient Substance Abuse 20% Coinsurance after deductible
Home Healthcare 20% Coinsurance after deductible, 60 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit 20% Coinsurance after deductible
Labor & Delivery Hospital Stay 20% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children 50% Coinsurance after deductible
Vision Screening for Children 50% Coinsurance after deductible, 1 Visit(s) per Year
Eye Glasses for Children 50% Coinsurance after deductible, 1 Item per Year, 1 pair of lenses per year, 1 frame every 2 years
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage 20% Coinsurance after deductible, 20 Visit(s) per Year
Durable Medical Equipment 20% Coinsurance after deductible
Hospice 20% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $5,000/$10,000
Out-of-Network Annual Coinsurance 40% Coinsurance
Out-of-Network Annual Out-of-Pocket Limit $14,000/$28,000
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 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.

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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.