Humana Gold 2250 Chicago HMOx


HumanaOne Illinois Dental Plan insurance
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Humana Gold 2250/Chicago HMOx

Important Questions

Answers

Why this Matters:

What is the overall deductible?

$2,250 Individual / $4,500 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.  $3,500 Individual / $7,000 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-ofpocket 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

$20 copay/visit

Not Covered

—none—

Specialist visit

$40 copay/visit

Not Covered

Other practitioner office
visit

Chiropractor Exam:
20% coinsurance after
deductible
Retail Clinic:
$30 copay/visit

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)

$500/calendar year paid at
100%; then 20%
coinsurance after ded.

Not Covered

—none—

Imaging (CT/PET scans,
MRIs)

20% coinsurance 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-Rx5-Plus or click here

Level 1 – Preferred generics

$5 copay (Retail)
$15 copay (Mail order)

Not covered

30 day supply (Retail)
90 day supply (Mail Order)

Level 2 – Non-preferred generics

$10 copay (Retail)
$30 copay (Mail order)

Not covered

Level 3 – Preferred brands

$20 copay (Retail)
$60 copay (Mail order)

Not covered

Level 4 – Non-preferred brands

30% coinsurance

Not covered

Level 5 – Specialty drugs

30% coinsurance

Not covered

Specialty Drugs: 25% coinsurance when filled via a preferred network pharmacy.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% coinsurance after deductible

Not Covered

—none—

Physician/surgeon fees

20% coinsurance after deductible

Not Covered

—none—

If you need immediate medical attention

Emergency room services

$250 copay/visit. Deductible, then 20% coinsurance

$250 copay/visit. Deductible, then 20% coinsurance

—none—

Emergency medical transportation

20% coinsurance after deductible

20% coinsurance after deductible

—none—

Urgent care

$40 copay/visit

Not Covered

—none—

If you have a hospital stay

Facility fee (e.g., hospital
room)

20% coinsurance after deductible

Not Covered

Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.

Physician/surgeon fee

20% coinsurance after deductible

Not Covered

—none—

If you have mental
health, behavioral
health, or
substance abuse
needs

Mental/Behavioral health
outpatient services

$20 copay/visit and 20%
coinsurance for other
outpatient services

Not Covered

—none—

Mental/Behavioral health
inpatient services

20% coinsurance after
deductible

Not Covered

Preauthorization may be required. Penalty will be $1,000
or 50% coinsurance, whichever is less.

Substance use disorder
outpatient services

$20 copay/visit and 20%
coinsurance for other outpatient services

Not Covered

—none—

Substance use disorder
inpatient services

20% coinsurance after
deductible

Not Covered

Preauthorization may be required.

If you are pregnant

Prenatal and postnatal
care

20% coinsurance after
deductible

Not Covered

—none—

Delivery and all inpatient
services

20% coinsurance after
deductible

Not Covered

—none—

If you need help
recovering or have
other special
health needs

Home health care

20% coinsurance after
deductible

Not Covered

Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.

Rehabilitation services

20% coinsurance 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

20% coinsurance after deductible

Not Covered

Skilled nursing care

20% coinsurance after deductible

Not Covered

Preauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.

Durable medical
equipment

20% coinsurance after deductible

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

50% coinsurance after deductible

Not covered

1 exam per year.

Glasses

50% coinsurance after deductible

Not covered

1 pair of glasses/frames per year.

Dental check-up

Not covered

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 outide 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.