Humana Silver 3800 Chicago HMOx
Humana Silver 3800/Chicago HMOx
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Important Questions |
Answers |
Why this Matters: |
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What is the overall deductible? |
$0 Individual / $0 Family |
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. |
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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. |
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Is there an out-of-pocket limit on my expenses? |
Yes. $0 Individual / $0 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. |
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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. |
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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. |
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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. |
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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. |
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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. |
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Common |
Services You May |
Your Cost If You |
Your Cost If You Use an Out-of-Network Provider |
Limitations & Exceptions |
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If you visit a |
Primary care visit to treat |
No charge |
Not Covered |
—none— |
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Specialist visit |
No charge |
Not Covered |
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Other practitioner office |
Chiropractor Exam: |
Not Covered |
Acupuncture not covered. |
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Preventive care/ |
No charge |
Not Covered |
—none— |
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If you have a test |
Diagnostic test (x-ray, |
No charge |
Not Covered |
—none— |
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Imaging (CT/PET scans, |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or |
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If you need drugs to treat your illness or condition |
Level 1 – Preferred generics |
$0 copay (Retail) |
Not covered |
30 day supply (Retail) |
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Level 2 – Non-preferred generics |
$0 copay (Retail) |
Not covered |
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Level 3 – Preferred brands |
$0 copay (Retail) |
Not covered |
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Level 4 – Non-preferred brands |
0% coinsurance |
Not covered |
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Level 5 – Specialty drugs |
0% coinsurance |
Not covered |
Specialty Drugs: 40% coinsurance when filled via a preferred network pharmacy. |
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If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
No charge |
Not Covered |
—none— |
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Physician/surgeon fees |
No charge |
Not Covered |
—none— |
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If you need immediate medical attention |
Emergency room services |
No charge |
No charge |
—none— |
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Emergency medical transportation |
No charge |
No charge |
—none— |
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Urgent care |
No charge |
Not Covered |
—none— |
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If you have a hospital stay |
Facility fee (e.g., hospital |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less. |
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Physician/surgeon fee |
No charge |
Not Covered |
—none— |
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If you have mental |
Mental/Behavioral health |
No charge |
Not Covered |
—none— |
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Mental/Behavioral health |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 |
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Substance use disorder |
No charge |
Not Covered |
—none— |
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Substance use disorder |
No charge |
Not Covered |
Preauthorization may be required. |
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If you are pregnant |
Prenatal and postnatal |
No charge |
Not Covered |
—none— |
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Delivery and all inpatient |
No charge |
Not Covered |
—none— |
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If you need help |
Home health care |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less. |
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Rehabilitation services |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or |
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Habilitation services |
No charge |
Not Covered |
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Skilled nursing care |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or |
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Durable medical |
No charge |
Not Covered |
Preauthorization may be required. Penalty will be $1,000 or |
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If your child needs dental or eye care |
Eye exam |
No charge |
Not covered |
1 exam per year. |
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Glasses |
No charge |
Not covered |
1 pair of glasses/frames per year. |
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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.) |
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| 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.) |
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