Colorado Annual Max 75/55
View HumanaOne's other Annual Max plan: Annual Max 50/30.
For more information regarding Participating and Non-participating providers, please see footnotes (8) and (9).
| Plan pays for services from NETWORK providers | Plan pays for services from NON-NETWORK providers | ||||||
| Deductible options 1 • per calendar year • copayments do not apply | • individual • family (three family members must each meet their individual deductible) | $1,000, $2,000 or $3,000 $3,000, $6,000 or $9,000 | $2,000, $4,000 or $6,000 $6,000, $12,000 or $18,000 | ||||
| Annual maximum options • per calendar year • all covered services apply | $100,000 or $250,000 paid by plan per covered person | ||||||
| Outpatient services maximum options • per calendar year • reduces annual maximum | $5,000 paid by plan for $100,000 annual maximum $5,000 or $10,000 paid by plan for $250,000 annual maximum | ||||||
| Coinsurance out-of-pocket limit 1 • per calendar year • deductibles and copayments do not apply | • individual • family | $3,500 $7,000 | $10,000 $20,000 | ||||
| Preventive care | • Well-child care (including immunizations)(birth to age 13) • prostate screening and digital rectal exam • mammogram • preventive office visits (age 13 and older)2 • routine immunizations (ages 13 to 18)2 • Pap smears2 • preventive lab and X-ray2 |
75% 75% 75% after deductible |
55% Not covered Not covered | ||||
| Physician services |
| 100% after office visit copay of $35 for primary care and $50 for specialty care up to 3 combined visits, then 75% after deductible 75% after deductible | 55% after deductible 55% after deductible | ||||
| First $100 per calendar year 100% then 75% after deductible4 75% after deductible | 55% after deductible 55% after deductible | |||||
| 75% after deductible | 55% after deductible | |||||
| Facility services | • inpatient and outpatient services • outpatient surgery • emergency services (copayment waived if admitted) | 75% after deductible 75% after $125 copay per visit and deductible | 55% after deductible 55% after $125 copay per visit and deductible | ||||
| Rx4 prescription drug5 | • benefit maximum (per covered person per calendar year) • deductible per covered person • copay for each prescription or refill (up to 90-day supply, with applicable copay for each 30 day supply) | $2,500 paid by plan Separate $500 deductible*
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| • benefit per prescription or refill • mail order (up to 90-day supply) | 100% after prescription copay 100% after three times retail copay | 70% after prescription copay 70% after three times retail copay | |||||
| Other medical services • prior authorization required in order to be eligible for these benefits | • skilled nursing facility (up to 30 days per calendar year) • hospice6 • home health care (up to 60 visits per calendar year) • durable medical equipment • pregnancy complications and sick baby services7 (no prior authorization required) • transplant services | 75% after deductible 75% after deductible when services are received from a Humana Transplant Network provider | 55% after deductible 55% after deductible covered expenses are limited to a maximum allowance of $35,000 per transplant | ||||
| Lifetime maximum benefit | $2,000,000 per covered person | ||||||
| Behavioral health (mental health, chemical and alcohol dependency) | • inpatient services • outpatient and office therapy sessions | Not covered | Not covered | ||||
| Optional benefits • these are available to add for an additional cost | • supplemental accident benefit ($500 or $1,000) (treatment must be provided within 90 days of the injury) | First $500 per accident at 100%, then base plan benefits apply or First $1,000 per accident at 100%, then base plan benefits apply | |||||
| Optional Dental Benefits | ||
Dental Traditional PlusThe Dental Traditional Plus plan meets all of your dental needs, with coverage for preventive, basic, and major services. You can choose any dentist, but you can save up to 30% on out-of-pocket costs when you visit one of the more than 125,000 participating network dentists. You can find a participating dentist by using our Dentist Finder. For more information about specific procedures, please view our full Summary of Benefits PDF (Dental can be found at the end). |
Dental Preventive PlusThe Dental Preventive Plus plan covers the most common preventive and basic services at an affordable price. YOu can choose any dentist from our extensive PPO network of more than 125,000 dentist locations. Use our Dentist Finder to see if your dentist is an in-network provider. For more information about specific procedures, please view our full Summary of Benefits PDF (Dental can be found at the end). |
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To be covered, expenses must be medically necessary and specified as covered. Please see your policy for more information on medical necessity and other specific plan benefits. | |
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1. When you obtain care from non-network providers: • your payment toward the deductible is NOT credited to the deductible for network providers • your out-of-pocket costs are NOT credited to the out-of-pocket maximum for network providers Once you meet your deductible and out-of-pocket expense limits, the plan pays 100 percent for covered services. 2. Benefit maximum for preventive care is limited to $300 per person per calendar year, subject to applicable coinsurance. 3. MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies are subject to applicable coinsurance after deductible. 4. This is a combined maximum to include diagnostic lab/X-ray/ interpretation, in a clinic or outpatient location. 5. If a non-network pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement. The covered person will also be responsible for 30% of the actual charge made by the dispensing pharmacy, after the applicable copayment. | 6. Bereavement limited to $1,150 per family for the 12-month period following death. Nursing, social/counseling services, and certified nurses aid or delegated nursing services, limited to $9,100 per member per benefit period. 7. This benefit also covers well-baby charges for a hospital stay of 48 hours following a vaginal delivery and 96 hours following a Cesarean section. If delivery occurs after 8:00 p.m., coverage will continue until 8:00 a.m. the following morning. 8. The Preferred Provider Organization (PPO) Network has an inadequate number of providers in the following counties in Colorado: Dolores, Gunnison, Hinsdale, Mineral, Ouray, Saguache, San Juan, San Miguel. 10. Non-network providers may balance bill you for the difference between the amount paid by us and the non-network providers billed charges if: • You are required to travel no more than a reasonable distance beyond the plan's service area in order to receive services from a network provider • The covered person knowingly seeks services from a non-network provider; and • The non-network provider is reimbursed for an amount less than the billed charge |
| Payments Network providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to non-network providers are based on maximum allowable fees, as defined in your policy. Non-network 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 copayment. 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. Network 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 judgement 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. To view Medical Limitations and Exclusions or Dental Limitations and Exclusions, please download a summary of plan benefits. | |
