Mississippi Annual Max 75/55
| 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 | · preventive office visits2,3 · child immunizations age 2 to 182,3 | 75% | Not covered | ||||
| · child immunizations birth to age 22,3 · Pap smear and mammogram · prostate screening · colorectal cancer screening (includes exam and lab tests) · endoscopic services (including, but not limited to colonoscopy) (includes exam and lab tests) · preventive lab and X-ray2,3 | 100% 100% 75% 75% after deductible | 100% 55% after deductible 55% after deductible 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 deductible5 75% after deductible | 55% after deductible 55% after deductible | |||||
| 75% after deductible | 55% after deductible | |||||
| Facility services | · inpatient and outpatient services · outpatient surgery6 · emergency services (copayment waived if admitted) | 75% after deductible 75% after $125 copay per visit and deductible | 55% after deductible 55% after $125 copayment per visit and deductible | ||||
| Rx4 prescription drug7 | · 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 copayment 100% after three times retail copay | 70% after prescription copayment 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) · 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 | ||||||
| Mental health | · inpatient services (up to 30 days per calendar year) · partial hospitalization and trasitional care (up to 60 days per calendar year) · outpatient and office therapy sessions (up to 52 visits per calendar year) | 75% after deductible | 55% after deductible | ||||
| 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) · Vision Direct Benefit | First $500 per accident at 100%, then base plan benefits apply or First $1,000 per accident at 100%, then base plan benefits apply $10 copay for exam with dilation as necessary1 $40 wholesale frame allowance after $15 copay2,3 20% retail discount on lenses | |||||
| Optional dental benefit (with teeth whitening) | 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 110,000 dentist locations in the PPO network. You can find a dentist by visiting Humana.com | |
| Preventive services plan pays 100% on deductible · oral examinations · routine cleanings · x-rays · sealants · topical fluoride treatment Basic services plan pays 50% after deductible · 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 Teeth whitening services plan pays 50% after deductible (six month waiting period applies) · $200 lifetime maximum | Major services plan pays for 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 Orthodontia: members can receive up to 20% 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 | |
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To be covered, expenses must be medically necessary and specified as covered. Please see your certificate 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 2. Benefit payable after 12-month waiting period for Preventive care. 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 is a combined maximum to include diagnostic lab/x-ray/interpretation, in a clinic or outpatient location. 6. Outpatient benefits payable after 90-day waiting period for nonemergency removal of tonsils and/or adenoids, and after 180-day waiting period for nonemergency surgical treatment for bunions, varicose veins, hemorrhoids or hernia (does not apply to strangulated or incarcerated hernia). 7. 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. |
| HumanaOne Vision Direct 1) Eye examination can include: - personal and family medical and ocular history; - visual acuity (unaided or acuity with present correction); - external exam; - papillary exam; - visual field testing (confrontation); - internal exam (direct or indirect ophthalmoscopy recording cup disc ratio, blood vessel status and any abnormalities); - biomicroscopy (i.e., cover test); - tonometry; - reflection (with recorded visual acuity); - extra ocular muscle balance assessment; - diagnosis and treatment plan. 2) The frame allowance is based on a wholesale price of $40, which typically equals a retail price of $120. This may vary by provider. 3) The frame allowance is in addition to $15 copay. 4) Frequency based on date of service. | |
| 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 certificate. 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 certificate 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 certificate will govern.
To view Medical Limitations and Exclusions please download a summary of plan benefits.
Important information regarding this association-based plan:
The Association, Peoples' Benefit Alliance, is a membership organization that provides educational information and discounts on goods and services to its members. In order to be eligible to apply for this health insurance coverage, membership in the Association is required.
