Humana Bronze 6450 Chicago HMO


HumanaOne Illinois Dental Plan insurance
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Humana Bronze 6450/Chicago HMOx

Important Questions Answers Why this Matters:
What is the overall deductible? $6,450 Individual / $12,900 Family
Doesn’t apply to preventive care. Coinsurance and copayments don’t count toward the deductible.
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out-of-pocket limit on my expenses? Yes.  $6,450 Individual / $12,900 Family The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out-of-pocket limit? Premiums, balance-billed charges, Penalties and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers? Yes.  See www.humana.com or call 1-800-833-6917 for a list of Network providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist? Yes. You need a referral to see a specialist. This plan will pay some or all of the costs to see a specialist for covered services, but only if you have the plan’s permission before you see the specialist.
Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.
Common
Medical Event
Services You May
Need

Your Cost If You
Use an In-Network Provider

Your Cost If You Use an Out-ofNetwork Provider Limitations & Exceptions
 

If you visit a
health care
provider’s office
or clinic

Primary care visit to treat
an injury or illness
No charge after deductible Not Covered —none—
Specialist visit No charge after deductible Not Covered
Other practitioner office
visit
Chiropractor Exam:
No charge after deductible
Retail Clinic:
No charge after deductible
Not Covered Acupuncture not covered.
Preventive care/
screening/immunization
No charge Not Covered —none—
If you have a test Diagnostic test (x-ray,
blood work)
No charge after deductible Not Covered —none—
Imaging (CT/PET scans,
MRIs)
No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at:
www.humana.com/
2016-HDHP-Plus
or click here
Generic and brand-name drugs No charge after deductible Not covered
Not covered
Not covered
Not covered
Not covered
30 day supply (Retail)
90 day supply (Mail Order)
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge after deductible Not Covered —none—
Physician/surgeon fees No charge after deductible Not Covered —none—
If you need immediate medical attention Emergency room services No charge after deductible No charge after deductible —none—
Emergency medical transportation No charge after deductible No charge after deductible —none—
Urgent care No charge after deductible Not Covered —none—
If you have a hospital stay Facility fee (e.g., hospital
room)
No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.
Physician/surgeon fee No charge after deductible Not Covered —none—
If you have mental
health, behavioral
health, or
substance abuse
needs
Mental/Behavioral health
outpatient services
No charge after deductible Not Covered —none—
Mental/Behavioral health
inpatient services
No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000
or 50% coinsurance, whichever is less.
Substance use disorder
outpatient services
No charge after deductible Not Covered —none—
Substance use disorder
inpatient services
No charge after deductible Not Covered Preauthorization may be required.
If you are pregnant Prenatal and postnatal
care
No charge after deductible Not Covered —none—
Delivery and all inpatient
services
No charge after deductible Not Covered —none—
If you need help
recovering or have
other special
health needs
Home health care No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.
Rehabilitation services No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less. – 72 visits per calendar year for Cardiac Therapy. 40 visits per calendar year for Spinal manipulations, adjustments, modalities. Any limits for Habilitation services and Rehabilitation services are combined.
Habilitation services No charge after deductible Not Covered
Skilled nursing care No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
Durable medical
equipment
No charge after deductible Not Covered Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
Hospice service No charge Not Covered Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
If your child needs
dental or eye care
Eye exam No charge Not Covered 1 exam per year.
Glasses No charge Not Covered 1 pair of glasses/frames per year.
Dental check-up No charge Not Covered —none—

 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Acupuncture
  • Cosmetic Surgery
  • Dental care (Adult)
  • Long Term Care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • Bariatric Surgery for morbid obesity
  • Chiropractic Care
  • Hearing aids
  • Infertility Treatment
  • Private-duty nursing (home health care)
  • Routine foot care when in treatment for diabetes.