| 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 | Your Cost If You Use an Out-of–Network 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.) |
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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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