Humana Gold 2250 Chicago HMOx


HumanaOne Illinois Dental Plan insurance
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Humana Gold 2250 Chicago HMOx
Humana Gold 2250/Chicago HMOx

Important QuestionsAnswersWhy 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 FamilyThe 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 ProviderLimitations & Exceptions
 

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

Primary care visit to treat
an injury or illness
$20 copay/visitNot Covered—none—
Specialist visit$40 copay/visitNot Covered
Other practitioner office
visit
Chiropractor Exam:
20% coinsurance after
deductible
Retail Clinic:
$30 copay/visit
Not CoveredAcupuncture not covered.
Preventive care/
screening/immunization
No chargeNot Covered—none—
If you have a testDiagnostic 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 CoveredPreauthorization 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 covered30 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 brands30% coinsuranceNot covered
Level 5 – Specialty drugs30% coinsuranceNot coveredSpecialty Drugs: 25% coinsurance when filled via a preferred network pharmacy.
If you have outpatient surgeryFacility fee (e.g., ambulatory surgery center)20% coinsurance after deductibleNot Covered—none—
Physician/surgeon fees20% coinsurance after deductibleNot Covered—none—
If you need immediate medical attentionEmergency room services$250 copay/visit. Deductible, then 20% coinsurance$250 copay/visit. Deductible, then 20% coinsurance—none—
Emergency medical transportation20% coinsurance after deductible20% coinsurance after deductible—none—
Urgent care$40 copay/visitNot Covered—none—
If you have a hospital stayFacility fee (e.g., hospital
room)
20% coinsurance after deductibleNot CoveredPreauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.
Physician/surgeon fee20% coinsurance after deductibleNot 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 CoveredPreauthorization 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 CoveredPreauthorization may be required.
If you are pregnantPrenatal 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 care20% coinsurance after
deductible
Not CoveredPreauthorization may be required. Penalty will be $1,000 or 50% coinsurance, whichever is less.
Rehabilitation services20% coinsurance after deductibleNot CoveredPreauthorization 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 services20% coinsurance after deductibleNot Covered
Skilled nursing care20% coinsurance after deductibleNot CoveredPreauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
Durable medical
equipment
20% coinsurance after deductibleNot CoveredPreauthorization may be required. Penalty will be $1,000 or
50% coinsurance, whichever is less.
If your child needs dental or eye careEye exam50% coinsurance after deductibleNot covered1 exam per year.
Glasses50% coinsurance after deductibleNot covered1 pair of glasses/frames per year.
Dental check-upNot coveredNot 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.