Humana One Traditional PPO Plan - Indiana
INDIANA Plan 49, Option 001
Lifetime Maximum Benefit
$5,000,000 per covered person (combined network and non-network)
Calendar-year Deductible1,2
$500 individual / $1,500 family3
$1,000 individual / $3,000 family
3
$1,000 individual / $3,000 family3
$2,000 individual / $6,000 family
3
$2,500 individual / $5,000 family3
$5,000 individual / $10,000 family
3
$5,000 individual / $10,000 family3
$10,000 individual / $20,000 family
3
• Deductible Carryover
Covered expenses incurred in the last three months of the calendar year and applied to the deductible will be credited to the next calendar year deductible.
Out-of-Pocket Maximum1,2
Applies to each covered person (no combined family limit)
Deductible + $2,000
Deductible + $8,000
• Routine annual physical exam
20% not subject to deductible
Not covered
• Routine immunizations (to age 18)
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• Routine Pap smears and PSA5
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• Routine Mammograms5
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• Colorectal cancer screening, related exams and lab tests
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• Routine lab, pathology and X-ray
20% after deductible
Not covered
• Office visits (includes diagnostic lab and X-ray)
20% after deductible
40% after deductible
• Allergy testing, injections and serum
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• Outpatient services (includes surgery)
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Hospital Services
20% after deductible
40% after deductible
• Outpatient surgery - facility
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• Outpatient non-surgical
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• Emergency room (including physician visits)
20% after $75 co-pay per visit and deductible (co-pay waived if admitted)
40% after $75 co-pay per visit and deductible (co-pay waived if admitted)
Prescription Drugs6
$500 prescription drug deductible per individual applies to combined Retail and Mail Order prescriptions
Retail Prescription Drugs2
Payment for each prescription or refill (up to 30-day supply)
•
Level one - lowest co-payment for lowest cost generic
and brand-name drugs$10 co-pay after prescription drug deductible
Member pays 30% after $10 co-pay after prescription drug deductible
•
Level Two - higher co-payment for higher cost generic
and brand-name drugs
$30 co-pay after prescription drug deductible
Member pays 30% after $30 co-pay after prescription drug deductible
•
Level Three - higher co-payment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic
equivalents in Levels One or Two
$50 co-pay after prescription drug deductible
Member pays 30% after $50 co-pay after prescription drug deductible
•
Level Four - highest co-payment for high technology drugs (certain brand-name drugs, biotechnology drugs and self-administered injectable medications)
25% co-pay after prescription drug deductible (up to $2,500 maximum out-of-pocket per calendar year)
Member pays 30% after 25% co-pay after prescription drug deductible (up to $2,500 maximum out-of-pocket per calendar year)
Mail Order Prescription Drugs2
Payment for each prescription or refill (90-day supply)
Three times the retail co-pay
Member pays 30% after three times the retail co-pay
• Skilled nursing facility (up to 30 days per calendar year)7
20% after deductible
40% after deductible
• Home health care (up to 60 visits per calendar year)7
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• Durable medical equipment7
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• Complications of pregnancy and sick baby services
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• Transplant services (organ)7
20% after deductible (when services are performed at a National Transplant Network provider)
40% after deductible (subject to separate out-of-pocket maximum of $35,000 per calendar year)
Alcohol and Chemical Dependence
•
Inpatient care and Outpatient care (Combined $2500 per calendar year maximum benefit, with Outpatient care not to exceed $500 of the $2,500 per calendar year maximum benefit.)50% after deductible
50% after deductible
Mental Disorders
• Inpatient
20% after deductible
40% after deductible
Optional Benefits9
• Prescription Drug, no deductible
Under this option, no deductible is required to be met before plan benefits are payable.
• Maternity including routine newborn care2
40% after $500 maternity deductible
60% after $1,000 maternity deductible
•
Office visit co-payment option - includes office diagnostic tests, lab and X-rays, paid at 100% up to $100 per calendar year. Does not apply to
preventive/routine care
2,10100% after $25 co-pay for primary care physician and $40 co-pay for specialist limited to four combined visits
(PCP and specialist) per calendar year. After four visits, Humana pays 80% after deductible.
40% after deductible
• Humana One Term Life
Available as option - additional cost
1
When you obtain care from nonparticipating providers, 50 percent of your payment toward the deductible is credited to the deductible for participating providers. Once you meet your single or family (if applicable) deductible and out-of-pocket expense
limits, the plan pays 100 percent for covered services.
2
Copayments do not apply to the deductible or out-of-pocket maximum. The medical out-of-pocket maximum does not apply to transplant services from non-participating providers, prescription drugs, mental health services or
maternity, if the optional maternity benefit is selected..
3
Two or three family members must meet their individual deductible, depending on the deductible amount selected.
4
$300 of covered expenses per person per calendar year, subject to applicable coinsurance.
5
Age and/or frequency limits apply.
6
If a nonparticipating pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement.
7
Prior authorization required in order to be eligible for these benefits.
8
Counseling for hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
9
These benefits are optional and can be added to your plan for an additional cost.
10
This benefit does not cover MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies. Primary care physicians include family practitioner, general practitioner, pediatrician or internist;
specialist contains any other participating physician.
Payments
Participating providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other co-payments. Plan benefits paid to nonparticipating providers are based on maximum
allowable fees, as defined in your policy.
Nonparticipating providers may balance bill you for charges in excess of the maximum allowable fee. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or co-payment.
Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible.
Participating Providers
Participating primary care and specialist physicians and other providers in Humana’s networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of
medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you.
This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms
and conditions of the policy will govern.
