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Type of Plan
GA Bronze 60/60 GA Silver 60/60
GA Silver 80/60
In-Network Calendar Year Deductible
Single
$6,700
$5,000
$1,500
Family
$13,400
$10,000
$3,000
Single
$7,150
$6,500
$7,150
Family
$14,300
$13,000
$14,300
Lifetime Maximum
Unlimited
(Some benefits may have limitations)
Unlimited
(Some benefits may have limitations)
Unlimited
(Some benefits may have limitations)
In-Network Coinsurance
Plan Pays 60%
after Deductible
Plan Pays 60%
after Deductible
Plan Pays 80%
after Deductible
Primary Care
$50 Copay
$40 Copay
$40 Copay
Specialty Care
$110 Copay
$80 Copay
$80 Copay
Walk-in Clinics
$40 Copay
$40 Copay
$40 Copay
Urgent Care
$100 Copay
$100 Copay
$100 Copay
Emergency Room
$1000 Copay
$550 Copay
$550 Copay
Preventive Care Services
Plan pays 100%
Plan pays 100%
Plan pays 100%
Advanced Imaging
Deductible, 60%
Deductible, 60%
Deductible, 80%
Hospital Inpatient Expenses
(Preauthorization Required)
Deductible, 60%
Deductible, 60%
Deductible, 80%
Hospital/Outpatient Facility
Expenses
(Preauthorization
Required)
Deductible, 60%
Deductible, 60%
Deductible, 80%
In-Network Mental Health and Alcohol/Drug Abuse Services
Inpatient Mental Health
Deductible, 60%
Deductible, 60%
Deductible, 80%
Outpatient Mental Health
$50 Copay
$40 Copay
$40 Copay
Level 1
$15 Copay
$10 Copay
$10 Copay
Level 2
$35 Copay
$20 Copay
$45 Copay, after $100 Individual
Deductible
Level 3
$75 Copay, after $500 Individual
Deductible
$50 Copay
$90 Copay, after $100 Individual
Deductible
Level 4
$135 Copay, after $500 Individual
Deductible
50% Coinsurance
25% Coinsurance, after $100
Individual Deductible
Level 5
$500 Copay, after $500 Individual
Deductible
50% Coinsurance
35% Coinsurance
Out of Network Benefits
See Summary of
Benefits and Coverage
See Summary of
Benefits and Coverage
See Summary of
Benefits and Coverage
Contact Information
Humana 866-427-7478
Medical Coverage Options - Humana - Traditional POS Plans
Prescription Drugs - Retail Pharmacy (30 day supply)
Mail Order Available.
In-Network Calendar Year Out of Pocket Maximum
In-Network Physician and Hospital Services
2