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Embedded
deductible
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
•
Advanced imaging
•
Spinal manipulations and adjustments (visit limits may
apply per calendar year)
80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
Individual: $2,900
Family: $5,800
Individual: $8,700
Family: $17,400
Individual: $5,000
Family: $10,000
Individual: $15,000
Family: $30,000
70% after deductible
- Diagnostic laboratory and radiology (performed in an office) 80% after deductible
60% after deductible
60% after deductible
60% after deductible
80% after deductible
60% after deductible
60% after deductible
80% after deductible
60% after deductible
60% after deductible
Header Top Right
Effective dates starting 1/1/17
(includes pediatric dental and vision)
In-network
Out-of-network
•
Based on a calendar year
Limit includes copays, deductibles and coinsurance
(out-of-network limit excludes pharmacy)
80% after deductible
80% after deductible
60% after deductible
80% after deductible
80% after deductible
80% after deductible
60% after deductible
60% after deductible
Embedded
out-of-pocket
maximum
Prescription drugs
•
Retail: 30-day supply
•
Mail order (up to 90-day supply)
A detailed HDHP EHB
drug list is available at
Humana.com/druglist.•
Specialty drugs (up to 30-day supply)
Embedded
- All covered benefits apply to the individual and family deductible and maximum out-of-pocket. When any family
member reaches the individual deductible amount, that family member will begin receiving coinsurance benefits - even if the
family deductible has not been met.
•
Based on a calendar year
80% after deductible
60% after deductible
HumanaNPOS 17
Option 5
Georgia 80/60 HDHP Plan
4