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HumanaOne – Portrait Share 80 Plus Rx Unlimited – Plan Benefits

HumanaOne – Portrait Share 80 Plus Rx Unlimited – Plan Benefits

Plan Feature In-Network Out-of-Network
Lifetime Maximum Benefit Unlimited
Individual Deductible1
Per individual, per calendar year. (For family coverage, two family members must each meet the individual deductible.)		 $1,000 or $2,500 2,000 or $5,000
Family Deductible1
For family coverage, two family members must each meet the individual deductible		 $2,000 or $5,000 $4,000 or $10,000
Carryover Deductible
Covered expenses incurred in the last three months of the calendar year and applied to the deductible will be credited to the next calendar year deductible.
Office Visit Copayments
Unlimited visits for illness or injury		 $35 primary care physician/$50 specialist None, subject to deductible and coinsurance
Individual Out-of-Pocket Expense Limit1
The maximum amount of money an individual pays toward covered hospital and medical expenses during any one calendar year. Deductibles and copayments do not apply		 $2,000 $8,000
Family Out-of-Pocket Expense Limit1 $4,000 $16,000
Preventive Care

  • Preventive Office Visits2,3
  • Chilid Immunizations to age 182,3
  • Pap Smear2,3
  • Mammogram
  • Prostate Screening2,3
  • Colorectal Cancer Screening, Related Exams and Lab Tests
 80% 50% after deductible
Preventive Lab and X-ray2,3 80% after deductible 50% after deductible
Physician Services
  • Office Visits (including allergy injections)
 100% after office visit copayment 60% after deductible
  • Diagnostic and X-Ray4, Allergy Testing
 First $200 per calendar year 100%, then 80% after deductible 60% after deductible
  • Allergy Serum, Inpatient and Outpatient Services, Surgery5
 80% after deductible 60% after deductible
Facility Services

  • Inpatient and Outpatient Services
  • Outpatient Surgery5
 80% after deductible 60% after deductible
Emergency Services
Copayment waived if admitted		 80% after $75 copayment per visit and deductible 60% after $75 copayment per visit and deductible
Other Medical Services

  • Skilled Nursing Facility (up to 30 days per calendar year)
  • Hospice7
  • Home Health Care (up to 60 visits per calendar year)
  • Durable Medical Equipment
  • Pregnancy Complications and Sick Back Services
 80% after deductible 60% after deductible
Transplant Services 80% after deductible when services are received from a Humana Transplant Network provider 60% after deductible – covered expenses are limited to a maximum allowance of $35,000 per transplant
Mental Health, Chemical and Alchohol Dependency2
$2500 per year, out-of-pocket maximum does not apply

  • Inpatient Services
  • Outpatient and Office Therapy Sessions (outpatient services not to exceed $500 of the total benefit)
 50% after deductible 50% after deductible
Prescription Drug Benefit6 In-Network Out-of-Network
Deductible per individual Separate $500 deductible (does not apply to Level 1 drugs)
  • Level 1 – lowest copayment for lowest cost generic and brand-name drugs
 $15 copayment
  • Level 2 – higher copayment for higher cost generic and brand-name drugs
 $35 copayment
  • Level 3 – higher copayment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic equivalents in Levels One or Two
 $55 copayment
  • Level 4 – highest copayment for high-technology drugs (certain brand-name drugs, biotechnology drugs and self-administered injectable medications)
 25% copayment
Copayment Maximum
Applies to Level 4 drugs only		 $2500 per individual per calendar year
Mail Order
Up to a 90-day supply.		 100% after 3x retail 70% after 3x retail
Optional Benefits
These are available to add for an additional cost. Medical out-of-pocket maximum does not apply to drug coverage		 Benefit Description
Prescription Drug Deductible With this option no deductible is required before prescription benefits are payable
Supplemental Accident Benefit

  • $500 or $1000
  • Treatment must be provided within 90 days of injury
 First $500 per accident at 100%, then base plan benefits apply, or First $1,000 per accident at 100%, then base plan benefits apply
This page contains a general summary of benefits, exclusions and limitations and should not used to make policy determinations. To view Medical Limitations and Exclusions or Dental Limitations and Exclusions please download a summary of plan benefits.Please refer to the policy for the actual terms and conditions that apply.

To be covered, expenses must be medically necessary and specified as covered. Please see your policy for more information on medical necessity and other specific plan benefits.
1When you obtain care from non-network providers:

  • 50 percent of your payment toward the deductible is credited to the deductible for network providers
  • 50 percent of your out-of-pocket costs are credited to the out-of-pocket maximum for network providers

Once you meet your deductible and out-of-pocket expense limits, the plan pays 100 percent for covered services.
2Benefit payable after 90-day waiting period for preventive care and 12-month waiting period for mental health.
3Benefit maximum for preventive care is limited to $300 per person per calendar year, subject to applicable coinsurance.
4MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies are subject to applicable coinsurance after deductible.
5Outpatient 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).
6If 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.
7Counseling for the hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
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 policy. 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.

Eligibility
The issue ages for HumanaOne individual health plans are two months to 64.5 years. The maximum age for a dependent child is 25 years if the child is a full-time student and 19 years if the child is not a full-time student.

Pre-existing Conditions
A pre-existing condition is a sickness or bodily injury which was treated within the 24-month period prior to the covered person’s effective date of coverage or which produced symptoms that would cause an ordinarily prudent person to seek medical diagnosis or treatment within the 12-month period prior to the covered person’s effective date of coverage. Benefits for pre-existing conditions are not payable until the covered person’s coverage has been in force for 12 consecutive months with us. We will waive the pre-existing conditions limitation for those conditions disclosed on the application provided benefits relating to those conditions are not excluded. Conditions specifically excluded by rider are never covered.