Colorado Autograph Share 80 Plus Rx/Copay
View these other HumanaOne Autograph plans
Autograph Total Plus Rx HSA | Autograph Total HSA
| 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 (two family members must each meet their individual deductible) | $3,500, $5,000 or $6,000 $7,000, $10,000 or $12,000 | $7,000, $10,000 or $12,000 $14,000, $20,000 or $24,000 | ||||
| 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. | ||||||
| Office visit copayment | $35 primary care/$50 specialist limited to 6 combined primary and specialty care visits | Not applicable | |||||
| Coinsurance out-of-pocket limit 1 · per calendar year · deductibles and copayments do not apply | · individual · family | $2,000 $4,000 | $8,000 $16,000 | ||||
| Preventive care | · Well-child care (including immunizations)(birth to age 13) · prostate screening and digital rectal exam2 · mammograms2 · preventive office visits (age 13 and older)3 · routine immunizations (ages 13 to 18)3 · Pap smears2,3 · preventive lab and X-ray3 | 80% 80% 80% after deductible | 60% Not covered Not covered | ||||
| Physician services | · office visits (including allergy injections) · diagnostic lab and X-ray4 · allergy testing · allergy serum · inpatient and outpatient services, surgery | 100% after office visit copayment up to 6 combined primary care and specialty care visits, then 80% after deductible First $200 per calendar year 100% then 80% after deductible 80% after deductible | 60% after deductible 60% after deductible 60% after deductible | ||||
| Facility services | · inpatient and outpatient services · outpatient surgery5 · emergency services · newborn hospital stay5 | 100% after deductible | 70% after deductible | ||||
| Rx4 prescription drug6 · medical out-of-pocket maximum does not apply | · deductible per individual · copay for each prescription or refill (up to 90-day supply; with applicable copay for each 30 day supply) | Separate $1,000 deductible*
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| · copayment maximum (applies to Level 4 drugs only) | $2,500 per individual per calendar year | ||||||
| · benefit per prescription or refill · mail order (up to 90-day supply) | 100% after prescription copayment 100% after three times retail copay | 70% after prescription copayment7 70% after three times retail copay7 | |||||
| Other medical services · prior authorization required in order to be eligible for these benefits | · skilled nursing facility (up to 30 days per calendar year) · hospice8 · home health care (up to 60 visits per calendar year) · durable medical equipment · pregnancy complications and sick baby services (no prior authorization required) · transplant services | 80% after deductible 80% after deductible when services are received from a Humana Transplant Network provider | 60% after deductible 60% after deductible covered expenses are limited to a maximum allowance of $35,000 per transplant | ||||
| Lifetime maximum benefit | $5,000,000 per covered person | ||||||
| Mental health, chemical and alcohol dependency · $2,500 per calendar year · medical out-of-pocket maximum does not apply | · inpatient services · outpatient and office therapy sessions (outpatient services not to exceed $500 of the total benefit) | 50% after deductible | 50% after deductible | ||||
| Optional benefits · these are available to add for an additional cost · medical out-of-pocket maximum does not apply to drug coverage | · prescription drug deductible · lifetime maximum benefit · supplemental accident benefit ($500 or $1,000) (treatment must be provided within 90 days of the injury) | With this option $500 deductible is required before Rx benefits are payable Increase to $8,000,000 per covered person 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. | |
| 1. When you obtain care from non-network providers: · 50 percent of your payment toward the deductible is credited to the deductible for network providers · 50 percent of your out-of-pocket costs are 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. Age and/or frequency limit applies 3. Benefit maximum for preventive care is limited to $300 per person per calendar year, subject to applicable coinsurance. 4. MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies are subject to applicable coinsurance after deductible. 5. This benefit 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. 6. If a non-network pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement. | 7. The covered person will also be responsible for 30% of the actual charge made by the dispensing pharmacy, after the applicable copayment. 8. 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. 9. 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. | |
