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$55 primary care
Deductible
Office visit copay
100%
Preventive care
•
Office visit
Other services
•
Physician services
•
Laboratory and radiology
•
Pap smear
•
Mammogram
•
Prostate screening
•
Immunizations
•
Endoscopy
- Office visit
•
Facility services
- Retail clinic
- Urgent care
- Emergency
- Inpatient, outpatient, and surgical
- Inpatient
- Outpatient (surgical and non-surgical)
- Diagnostic laboratory and radiology
- Emergency room (copay waived if admitted)
•
Advanced imaging
•
Spinal manipulations and adjustments (visit limits may
apply per calendar year)
100% after office visit copay
100% after primary care copay
100% after $125 copay
100%
100%
100% after $2,350 copay per
day for the first three days
Individual: $0
Family: $0
Individual: $5,000
Family: $10,000
Individual: $7,150
Family: $14,300
Individual: $21,450
Family: $42,900
70% after deductible
- Diagnostic laboratory and radiology
100%
70% after deductible
70% after deductible
70% after deductible
100%
70% after deductible
70% after deductible
100% after $2,350 copay
70% after deductible
70% after deductible
In-network
Out-of-network
•
Based on a calendar year
Limit includes copays, deductibles and coinsurance
(out-of-network limit excludes pharmacy)
100%
100% after $850 copay
70% after deductible
100% after $850 copay
100% after $850 copay
100% after $110 copay
70% after deductible
70% after deductible
Out-of-pocket
maximum
$110 specialist
Not applicable
Effective dates starting 1/1/17
(includes pediatric dental and vision)
HumanaNPOS 17
Option 6
Georgia 100/70 Simplicity Plan
2