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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 $2,250 copay per
day for the first three days
Individual: $0
Family: $0
Individual: $5,000
Family: $10,000
Individual: $6,850
Family: $13,700
Individual: $20,550
Family: $41,100
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 $2,250 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 $750 copay
70% after deductible
100% after $750 copay
100% after $750 copay
100% after $100 copay
70% after deductible
70% after deductible
Out-of-pocket
maximum
$100 specialist
Not applicable
*Deductible may not apply to certain services.
HumanaNational POS 16
Option 4
Georgia 100/70 Simplicity Plan
GAHJCTTEN 9/15