Humana Together in Health (PPO I-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit $20%
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$612 per day for days 1 to 4
$0 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Coinsurance for Urgent Care 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0

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 $0

In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services $20%

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

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0

Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies $0
Coinsurance for Medicare Covered Diabetic Supplies 20%
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 20%

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC20% OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

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

Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0

Out-of-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital per Stay $1872

Out-of-Network:

Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%

Out-of-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%

In-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%

In-Network:
$30 monthly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider.
Unused amount rolls over to the next month and expires at the end of the plan year.

Out-of-Network:
95% coinsurance for approved over-the-counter health and wellness products up to $30 monthly allowance amount.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 20%
In-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 20%
Copayment for Routine Foot Care $0

• Maximum 4 visits every year

Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 100

In-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$1,000 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.

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0
Coinsurance for Medicare Covered Eye Exams 20%
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 20%

Out-of-Network:

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