|
Covered Benefit
|
Member Share
|
|
Plan Year Deductible
|
$0
|
|
Maximum Out-of-Pocket Expense
|
$2,000
|
|
Office Visit
Primary Care /Specialist
|
PCP – $0 Copay
Specialist – $10 Copay
|
|
Emergency Room
|
$50 co-pay per visit; waived if admitted within 24 hours
|
|
Inpatient Hospital
|
$50/day (days 1-10)
|
|
Prescription Drugs (Part D)
|
|
 Tier 1 – Preferred Generics and generics
|
- $0 copay
|
- Tier 2- Preferred Brand
|
- $20 copay
|
- Tier 3 – Non-Preferred Brand
|
- $40 copay
|
- Tier 4 Specialty
|
- 20% coinsurance
|
| You may view the formulary at www.humana.com |
|
Additional Benefits
|
|
|
Virtual Visits
|
Primary Care – 100%/ Specialist – $10 copay
Behavioral Health and Substance Abuse – 100% – $10 copay
|
|
Routine Hearing Exam
|
One hearing exam per year; up to $500 reimbursement allowance for hearing aids per year.
|
|
Routine Dental
|
$500 maximum benefit coverage amount per year for all preventive and comprehensive benefits.
|
|
Routine Vision
|
100% for routine exam, up to 1 per year
|
|
Meals after Inpatient Stay
|
28 meals available post-discharge
|
|
Silver Sneakers
|
A total health physical activity program included in your plan at no extra cost. www.silversneakers.com |
