Humana Essentials Plus Giveback (PPO)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $50%

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$545 per day for days 1 to 4
$0 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $325

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $325

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 19%
Prior Authorization Required for Durable Medical Equipment

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $100
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$40 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $345
Copayment for Medicare-covered Therapeutic Radiological Services $40
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $145

Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 50%

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $450
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$5 Hyperbaric Oxygen Treatment - OPH$0 Mental Health - OPH$450 Surgery Svcs - OPH$40 Wound Care - OPH

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $545
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $350
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$350 Surgery Svcs - ASC

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $40
Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 50%

In-Network:
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$25 copayment for amalgam and/or composite filling up to 2 per year.
$1,250 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$25 copayment for amalgam and/or composite filling up to 2 per year.
$1,250 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $40
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
$0 Diab Eye Exam - All POTs$40 Vision Svcs (MC) - SPC

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Maximum Plan Benefit of $150 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $75 less than the PLUS network.

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 50%

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0