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Louisiana Annual Max 75/55

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Download a Summary of Benefits

View HumanaOne's other Annual Max plan: Annual Max 50/30.

 
Plan pays for services at PARTICIPATING providers Plan pays for services at NON-PARTICIPATING providers
Annual Deductible
•Deductible options (1)
• per calendar year
• copayments do not apply
  •  
Single Deductible Family Deductible* Single Deductible Family Deductible*
$1,000
$2,000
$3,000
$3,000
$6,000
$9,000
$2,000
$4,000
$6,000
$6,000
$12,000
$18,000
 

*three family members must each meet their individual deductible

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 copays do not apply
  • individual
 $3,500 $10,000
  • family
 $7,000 $20,000
Preventive care
  • preventive office visits (2)
  • child immunizations age 6 to age 18 (2)
 75% 50% after deductible
  • child immunizations birth to age 6
  • Pap smear and mammogram
  • prostate screening
 75% 55%
  • preventive lab and X-ray (2)
 75% after deductible 50% after deductible
  • endoscopic services (including, but not limited to colonoscopy)
    (includes exam, lab tests and fecal occult blood test)
  • gynelogical care
 75% 55% after deductible
Physician services
Deductible $1,000 or $2,000
  • office visits for illness or injury (including allergy injections)
100% after office visit copay of $35 for primary care and $50 for specialty care up to 3 combined visits, then 75% after deductible 55% after deductible
  • diagnostic lab and X-ray (3)
  • allergy testing
 First $100 per calendar year 100% then 75% after deductible (4) 55% after deductible
  • allergy serum
  • inpatient and outpatient services
  • surgery
  • emergency services
 75% after deductible 55% after deductible
Physician services
Deductible $3,000
  • office visits for illness or injury (including allergy injections)
  • diagnostic lab and X-ray (3)
  • allergy testing
  • allergy serum
  • inpatient and outpatient services
  • surgery
  • emergency services
 75% after deductible 55% after deductible
Facility services
  • inpatient and outpatient services
  • outpatient surgery
 75% after deductible 55% after deductible
  • emergency services
    (copayment waived if admitted)
 75% after $125 copay per visit and deductible 55% after $125 copay per visit and deductible
Rx4 prescription drug (5)
  • benefit maximum (per covered person per calendar year)
 $2,500 paid by plan $2,500 paid by plan
  • deductible per covered person
 Separate $500 deductible* Separate $500 deductible*
  • copay for each prescription or refill (up to 90-day supply; with applicable copay for each 30 day supply)
 100% after prescription copay: 70% after prescription copay:
  • Level One -
$15 copayment
*no deductible 		$15 copayment
*no deductible
  • Level Two -
 $40 copayment $40 copayment
  • Level Three -
$65 copayment $65 copayment
  • Level Four -
25% 25%
  • mail order (up to 90-day supply)
 100% after three times retail 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)
  • hospice
  • home health care (up to 30 visits per calendar year)
  • durable medical equipment
  • pregnancy complications and sick baby services (no prior authorization required)
  • attention deficit hyperactivity disorder (6)
 75% after deductible 55% after deductible
  • transplant services
 75% after deductible when services are received from a Humana Transplant Network provider 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 		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 Individual Dental Insurance

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 110,000 dentist locations in the PPO network. You can find a dentist by visiting Humana.com. This is not a complete disclosure of plan qualifications and limitations. Please review the specific Dental Limitations and Exclusions before applying for coverage.

Preventive services plan pays 100% no deductible
  • oral examinations
  • routine cleanings
  • X-rays
  • sealants
  • topical fluoride treatment




Basic services plan pays 50% after deductible
• six month waiting period applies
  • emergency care for pain relief
  • thumb sucking and harmful habit appliances
  • space maintainers
  • amalgam, composite fillings (front/anterior teeth only)
  • oral surgery
  • routine extractions
  • non-cast stainless steel crowns
  • partial or complete denture repairs/adjustments


 Major services plan pays 50% after deductible
• twelve month waiting period applies
  • endodontics (root canals)
  • periodontics
  • crowns
  • inlays and onlays
  • partial or complete dentures
  • denture relines/rebases
  • removable or fixed bridgework

Teeth whitening pays 50% after deductible, $200 lifetime maximum
• six month waiting period applies

Orthodontia
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
  • $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:
   • your payment toward the deductible is NOT credited to the deductible for participating providers
   • your out-of-pocket costs are NOT credited to the out-of-pocket maximum for participating providers
(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 nonparticipating 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) Benefit maximum for attention deficit is limited to $600 for initial diagnosis; $50 per visit for outpatient services; $2,500 per calendar year and $10,000 per lifetime maximum.

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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