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Kansas Autograph Share 80 Plus Rx and Copay

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View these other HumanaOne Autograph plans
Autograph Total Plus Rx HSA | Autograph Total HSA

 
Plan pays for services at PARTICIPATING providers Plan pays for services at NON-PARTICIPATING providers
Annual Deductible
(1), (2)
  • Annual amount (does not apply to maximum out-of-pocket expense)
Single Deductible Family Deductible* Single Deductible Family Deductible*
$5,000
$6,000
$10,000
$12,000
$10,000
$12,000
$20,000
$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.

*Two family members must meet their individual deductible.

Maximum Out-of-Pocket Expense Limit (1), (2)
  • Individual
 $2,000 $8,000
  • Family
 $4,000 $16,000
Lifetime Maximum Benefit  

$5,000,000 per covered person
Preventive Care
  • Routine immunizations (birth to 72 months)
 100% 100%
  • Routine annual physical exam (4)
  • Routine immunizations (72 months to age 18) (4)
 80% 50% after deductible
  • Routine Pap smears and PSA (5)
  • Routine mammograms (5)
  • Digital rectal exams (5)
 80% 60% after deductible
  • Routine lab, pathology and X-ray (4)
 80% after deductible 50% after deductible
Physician Services (2), (12), (13)
  • Office Visits:
    Primary care
    (limited to 6 combined (Primary Care and Specialty Care) visits/calendar year) (includes allergy injections)
 $35 copayment for 6 visits, then 80% after deductible 60% after deductible
  • Office Visits:
    Specialty care
    (limited to 6 combined (Primary Care and Specialty Care) visits/calendar year) (includes allergy injections)
 $50 copayment for 6 visits, then 80% after deductible 60% after deductible
  • Diagnostic lab, X-ray and allergy testing (10), (13)
 First $200 per calendar year at 100% then 80% after deductible 60% after deductible
  • Allergy serum
  • Inpatient services
  • Outpatient services (includes surgery)
80% after deductible 60% after deductible
Hospital Services
  • Inpatient care
  • Outpatient surgery - facility
  • Outpatient nonsurgical
 80% after deductible 60% after deductible
  • Emergency room (including physician visits)
 80% after $75 copayment per visit and deductible (copayment waived if admitted) 60% after $75 copayment per visit and deductible (copayment waived if admitted)
Prescription Drugs (6)
  • Prescription drug deductible (Covered prescription drugs are assigned to one of four different levels with corresponding copayment amounts.) (2)
 $1,000 prescription drug deductible per individual $1,000 prescription drug deductible per individual
  • Benefit for each prescription or refill (up to 30-day supply)
 100% after: 70% after:
  • Level One - lowest copayment for lowest cost generic and brand-name drugs
 $15 copayment (not subject to prescription drug deductible) $15 copayment (not subject to prescription drug deductible)
  • Level Two - higher copayment for higher cost generic and brand-name drugs
 $35 copayment after prescription drug deductible $35 copayment after prescription drug deductible
  • Level Three - higher copayment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic equivalents in Levels One or Two
 $55 copayment after prescription drug deductible $55 copayment after prescription drug deductible
  • Level Four - highest copayment for high-technology drugs (certain brand-name drugs, biotechnology drugs and self-administered injectable medications)
 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year
  • Mail order (90-day supply)
 100% after three times the retail copayment 70% after three times the retail copayment
Other Medical Services
  • Skilled nursing facility (up to 30 days per calendar year) (7)
  • Home healthcare (up to 60 visits per calendar year) (7)
  • Durable medical equipment (7)
  • Hospice (7), (8)
  • Complications of pregnancy and sick baby services
 80% after deductible 60% after deductible
  • Transplant services (organ) (7)
 80% after deductible (when services are performed at a National Transplant Network provider) 60% after deductible (limited to $35,000 per covered transplant)
Mental Health (includes mental disorders, alcohol and chemical dependence)
  • Inpatient (up to 30 days per calendar year)
 80% after deductible 60% after deductible
  • Outpatient therapy
 100% of first $100; 80% of the next $100; 50% of the next $1,640; per calendar year 100% of first $100; 80% of the next $100; 50% of the next $1,640; per calendar year
  • Outpatient mental health lifetime maximum
 $7,500 per covered person $7,500 per covered person
Optional Benefits (9)
  • Prescription drug, $500 deductible
 Under this option, $500 deductible is required to be met before plan benefits are payable. Under this option, $500 deductible is required to be met before plan benefits are payable.
  • Lifetime maximum benefit
 $8,000,000 per covered person $8,000,000 per covered person
  • $500 Supplemental Accident Benefit (Treatment must be provided within 90 days of the injury.)
 First $500 per accident at 100%, then base plan benefits apply First $500 per accident at 100%, then base plan benefits apply
  • $1,000 Supplemental Accident Benefit (Treatment must be provided within 90 days of the injury.)
 First $1,000 per accident at 100%, then base plan benefits apply First $1,000 per accident at 100%, then base plan benefits apply
Optional Dental Benefits (with teeth whitening) (12)

You can choose any dentist, but you can save up to 30 percent on out-of-pocket costs when you visit one of the more than 75,000 dentist locations in the PPO network.  You can find a dentist by visiting www.humana.com.

Preventive services plan pays 100% no deductible
  • Oral examinations
  • Routine cleanings
  • X-rays
  • Sealants
  • Topical fluoride treatment

Basic services plan pays 50% after deductible
  • Emergency exams and palliative care for pain relief
  • Thumb sucking and harmful habit appliances
  • Space maintainers
  • Amalgam, composite fillings
  • Oral surgery
  • Extractions (routine)
  • Non-cast stainless steel crowns
  • Partial or complete denture repairs/adjustments

Teeth whitening services plan pays 50% after deductible
  • $200 lifetime maximum
 Major services plan pays 50% after deductible
  • Endodontics (root canals)
  • Periodontics
  • Crowns
  • Inlays and onlays
  • Partial or complete dentures
  • Denture relines/rebases
  • Removable or fixed bridgework

Orthodontia discount
Members can receive up to 20 percent discount if they visit an orthodontist from the HumanaDental PPO Network and ask for the discount.

Annual Deductible
  • $50 individual
  • $150 family

Annual maximum benefit
  • $1,000

 

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.
          - 50 percent of your out-of-pocket costs are credited to the out-of-pocket maximum for participating providers.
Once you meet your 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 prescription drugs or mental health services.
(3) Two family members must meet their individual deductible.
(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 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.
(9) These benefits are optional and can be added to your plan for an additional cost. Optional benefits may not be available in all areas.
(10) This benefit does not cover MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies.
(11) 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.
(12) Primary care physicians include family practitioner, general practitioner, gynecologist, pediatrician or internist; specialist contains any other participating physician. Please contact Customer Service for details.
(13) Does not apply to preventive/routine care.

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

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.

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