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 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 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) Must meet deductible in addition to the out-of-pocket maximum.
(3) For other than single coverage, the family deductible applies. The single deductible applies to single coverage policies only.
(4) $300 of covered expenses per person per calendar year, subject to applicable coinsurance.
(5) Age and/or frequency limits apply.
(6) Prior authorization required in order to be eligible for these benefits.
(7) Counseling for the hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
(8) These benefits are optional and can be added to your plan for an additional cost. Optional benefits may not be available in all areas.
(9) This is not a complete disclosure of plan qualifications and limitations. Waiting periods apply: six months on basic services and teeth whitening, 12 months on major services. Please review the specific Dental Limitations & Exclusions before applying for coverage.
(10) There is no coverage for retail and/or mail order prescription drugs unless stated in the policy.

To view Medical Limitations and Exclusions or Dental Limitations and Exclusions please download a summary of plan benefits.

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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 copayments. 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 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.

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 judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you.