Humana Silver 3650/National POS - OpenAccess + Children's Dental
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Georgia
Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
About this plan Selecting your healthcare providers – When you
enroll in this plan, you can receive care from any
Humana Silver 3650/National POS – OpenAccess +
doctor, specialist or hospital you choose, but you will
Children’s Dental is a Point of Service (POS) health
save more money by choosing a provider within a
plan. You have a large network of healthcare providers
select group of healthcare providers in the network.
to choose any primary care physician (PCP) to help
You should choose a PCP from this group with whom
you maintain your health and well-being. You have
you can build a trusting relationship as they are your
the freedom to visit any doctor, specialist or hospital.
first point of contact to maintain your health and well-
However, your out-of-pocket costs are lower when you
being. You can receive healthcare services from any PCP
choose an in-network provider.
in this group, and you can use any specialist or hospital
›› This plan covers inpatient and outpatient medical
of your choice within the network without a referral
services, and includes prescription drug coverage.
from your PCP.
It also provides all preventive services and includes
›› To search for a PCP in your area, visit
most essential health benefits, like maternity and
Humana.com/findadoctor. Use your plan’s
childbirth. It does not include children’s dental.
network name to locate a PCP close to home.
Save for healthcare expenses with a Health Savings • The network name is National POS – OpenAccess
Account (HSA) – With this plan you can set aside
The pharmacy network – The pharmacy network
tax-free money to pay for qualified medical expenses
name is “National Rx Network.” This plan also gives
with an HSA. The funds always belong to you and help
you access to the mail order pharmacy, RightSource®.
you save for future health care needs. HSA funds can
Visit RightSourceRx.com.
be used to satisfy your deductible. Contact your local
›› To find a pharmacy in your area, visit Humana.com.
banking institution to open your HSA.
Once there, Humana’s easy-to-use Rx Tool will help
you find an in-network pharmacy in your area.
Who can apply for this plan – Any individual or family
can apply for this plan. There are three requirements:
You must live in the U.S., you must be a U.S. citizen
or national (or lawfully present), and you cannot be
currently incarcerated. (healthcare.gov)
This plan is available in the following counties: Banks, Barrow, Bartow, Bibb, Bleckley, Brantley, Bryan, Bulloch, Burke,
Butts, Camden, Candler, Carroll, Chatham, Chattahoochee, Cherokee, Clarke, Clayton, Cobb, Columbia, Coweta, Crawford,
Dawson, DeKalb, Douglas, Effingham, Emanuel, Evans, Fayette, Floyd, Forsyth, Fulton, Glascock, Glynn, Greene, Gwinnett,
Hall, Hancock, Haralson, Harris, Heard, Henry, Houston, Jackson, Jefferson, Jenkins, Johnson, Jones, Lamar, Laurens,
Liberty, Lincoln, Long, Madison, Marion, McDuffie, McIntosh, Monroe, Morgan, Muscogee, Newton, Oconee, Oglethorpe,
Paulding, Peach, Pickens, Polk, Rockdale, Richmond, Screven, Spalding, Stewart, Talbot, Taliaferro, Tattnall, Troup, Twiggs,
Walton, Warren, Washington, Wayne, Webster, Wilkes, Wilkinson.
GAHHWKAEN 1014 Page 1 of 12
POLICY NUMBER: GA-71037-01 4/2010Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
Date the plan starts – The initial Open Enrollment Insurance terms you should know:
period for 2015 coverage is November 15, 2014 to
February 15, 2015. Coverage can start as early as Coinsurance – A percentage of your medical and drug
January 1, 2015. After Open Enrollment you can enroll costs that you pay out of your pocket
in individual or family coverage if you have a qualifying
life event. Examples of qualifying life events are moving Copay – The fixed dollar amount you pay when you
to a new state, certain changes in your income and receive medical services or have a prescription filled
changes to your family size (e.g. if you marry, divorce or Deductible – The amount you pay for medical services
have a baby). (healthcare.gov) or prescriptions before your plan pays for your benefits
Out-of-network coverage – This plan gives you the Network – A group of healthcare providers or
freedom to receive care from any doctor, specialist or pharmacies who are contracted with Humana to
hospital you choose, but you will save more money provide medical services or prescription drugs at a
by using in-network healthcare providers. In addition, discounted rate; often referred to as “in-network”
you will save more money by having your prescriptions
filled at in-network pharmacies. This includes the mail Maximum out-of-pocket – The most you could pay
order service, RightSourceRx.com. toward covered expenses including deductibles, copays
and coinsurance
This document is for information only and contains a general summary of covered benefits, exclusions, and limitations.
Please refer to the plan’s medical insurance policy for a full list of benefits covered.
The medical insurance policy is a document that details the benefits and provisions of the plan, as well as limitations and
services that are not covered. Please see the “Limitations and exclusions” that are included in this document. If there are
discrepancies with the information given in this document, the terms and conditions of the medical insurance policy
will apply.
GAHHWKAEN 1014 Page 2 of 12
POLICY NUMBER: GA-71037-01 4/2010Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
In-network Out-of-network
Individual Family Individual Family
Combined The amount of covered expenses you’ll pay out of your $3,650 $7,300 $7,300 $14,600
medical, pocket before the plan pays for covered services
prescription
drug,
children’s
vision
care and
children’s
dental care
deductible*
Annual The most you pay toward the covered cost of your $3,650 $7,300 $14,600 $29,200
out-of- healthcare for the calendar year; includes deductibles,
pocket coinsurance and pharmacy charges; does not include
maximum* the premium
›› Once you reach your out-of-pocket maximum, the
plan pays 100% of all covered expenses
›› Deductible and out-of-pocket maximum start over
each new calendar year
Coinsurance* The percentage you pay for covered medical services This plan pays 100% You pay 25% of
of covered expenses covered expenses
after you pay your after you pay your
deductible deductible
*Family policies have a family deductible and family out-of-pocket maximum. This means that the entire family
deductible must be paid before coinsurance benefits are payable for any family member on the plan.
Lifetime The total amount this plan will pay for covered expenses Unlimited
maximum in your lifetime
Preventive Child Wellness Services, birth thru age 5, includes well This plan pays 100% You pay 25%
care office visit, lab tests, child immunizations, including
flu and pneumonia, preventive hearing and vision
screening.
Includes preventive office visits, lab tests, This plan pays 100% You pay 25%
X-rays, child immunizations (age 6-18), flu and after you pay your
pneumonia immunizations (age 6 and older), Pap deductible
tests, mammograms, prostate screening, certain
endoscopic services and more
Diagnostic Includes maternity and mental health services This plan pays 100% You pay 25%
office visits after you pay your after you pay your
and urgent deductible deductible
care centers
Diagnostic ›› Includes allergy testing This plan pays 100% You pay 25%
lab and ›› Includes maternity and mental health services after you pay your after you pay your
X-rays deductible deductible
GAHHWKAEN 1014 Page 3 of 12
POLICY NUMBER: GA-71037-01 4/2010Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
In-network Out-of-network
Emergency Emergencies are life-threatening illnesses or injuries This plan pays 100% after you pay your
room ›› Includes, but is not limited to, major head deductible
trauma, chest pain, severe abdominal pain, loss of
consciousness, amputation of a body part, severe
break or bone fracture and signs or symptoms of
stroke or heart attack
Ambulance This plan pays 100% after you pay your
deductible
Hospital Inpatient This plan pays 100% You pay 25%
stay ›› Facility fee (e.g. hospital room) after you pay your after you pay your
›› Physician/surgeon fees deductible deductible
Outpatient
›› Facility fee (e.g. ambulatory surgery center)
›› Physician/surgeon fees
Maternity Delivery and related inpatient and outpatient services This plan pays 100% You pay 25%
after you pay your after you pay your
deductible deductible
Transplants This plan pays 100% You pay 25%
when services are after you pay your
received from a deductible; this plan
Humana National pays up to $35,000
Transplant Network per transplant
provider after you pay
your deductible
Mental Mental illness and chemical/alcohol dependency This plan pays 100% You pay 25%
health ›› Includes inpatient and outpatient services after you pay your after you pay your
deductible deductible
Other Including, but not limited to: This plan pays 100% You pay 25%
medical ›› Skilled nursing facility – up to 30 days per calendar after you pay your after you pay your
services year deductible deductible
›› Physical and occupational therapy – combined, up to
20 visits per calendar year
›› Speech therapy – up to 20 visits per calendar year
›› Respiratory therapy – up to 30 visits per calendar year
›› Cognitive, audiology, and cardiac therapy – visit limits
do not apply
›› Spinal manipulations, adjustments, and modalities –
up to 20 visits per calendar year
›› Home healthcare services – up to 120 visits per
calendar year
›› Hospice Care
GAHHWKAEN 1014 Page 4 of 12
POLICY NUMBER: GA-71037-01 4/2010Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
In-network Out-of-network
Prescription The pharmacy network name is “National Rx This plan pays 100% This plan pays 100%
drugs Network” after you pay your of it’s required
›› You pay a copay for each covered prescription fill deductible portion, after you pay
or refill up to a 30-day supply at these in-network your deductible. You
pharmacies are responsible for
• This plan also gives you access to the mail order 100% of additional
pharmacy, RightSource charges.
• Visit RightSourceRx.com
• Mail order through RightSourceRx.com covers up
to a 90 day supply at 100% after you pay your
deductible
›› If you use an out-of-network pharmacy, you’ll need to
pay the full cost up front and then ask Humana to pay
you back by submitting a claim
• Find out what drugs are included at Humana.com
with the Rx Tool
• The prescription drug plan name is HDHP Plus
Children’s Children, up to age 19, are covered under this plan This plan pays 100% This plan pays 100%
vision care ›› Exam with dilation as necessary (limit 1 per year) after you pay your after you pay your
›› Medically necessary eyeglass lenses with covered deductible deductible
frames or contact lenses (limit 1 per year)
• Eyeglass lens options – standard polycarbonate and/
or standard scratch coating
›› Low vision
• Supplemental testing (limit 1 every 2 years)
›› Vision aids (limit 1 every 3 years)
• Video magnification aids (1 every 5 years)
• If you buy a frame outside of the selection, the plan
provides a benefit up to the amount that would have
been paid if you chose a frame from the selection;
additional discounts may be available with network
providers
• The above services are not all inclusive; see the plan’s
medical insurance policy for more details
GAHHWKAEN 1014 Page 5 of 12
POLICY NUMBER: GA-71037-01 4/2010Humana Silver 3650/National POS – OpenAccess
+ Children’s Dental
In-network Out-of-network
Children’s Children, up to age 19, are covered under this plan This plan pays 100% This plan pays 100%
dental care ›› Diagnostic and preventive services after you pay your after you pay your
• Routine oral exams, periodontal exams, cleanings deductible deductible
(limit 2 each per year)
• Bitewing X-rays (limit 2 sets per year, excludes full
mouth and panoramic)
• Topical fluoride treatment (limit 2 per year, age 18
and under)
• Sealant (limit 1 tooth per 3 years, age 18 and under)
›› Minor restorative services and surgical
• Prefabricated crowns (limit 1 per 5 years, primary
teeth only)
• Fillings
›› Major restorative services
• Resin onlays, inlays and crowns (limit 1 per tooth per
5 years, permanent teeth only)
›› More than 225,000 dentist locations in the Humana
Dental PPO network. Visit Humana.com/findadoctor
to find dentists in your area
GAHHWKAEN 1014 Page 6 of 12
POLICY NUMBER: GA-71037-01 4/2010Network agreements
Network providers (also called in-network providers) agree to accept an agreed-upon amount as payment in full. Your
policy explains your share of the cost of services rendered by network providers. The plan may include a deductible, a set
amount (copay), and a percent of the costs (coinsurance)
When you go to an in-network provider: When you go to an out-of-network provider:
• The amount you pay is based on the agreed-upon • The amount you pay for health benefits is based on
amount. Humana’s maximum allowable fee. The amount you
• The provider can’t “balance bill” you for charges greater pay for dental and vision benefits is based on Humana’s
than that amount. reimbursement limit.
• The provider can balance bill you for charges greater than
the maximum allowable fee and/or the reimbursement
limit.
Limitations and exclusions (things that are not covered)
This is an outline of the limitations and exclusions for the Humana individual health plan listed above. It is designed
for convenient reference. Consult the policy for a complete list of limitations and exclusions. Certain services and
prescription drugs require preauthorization and notification before services are rendered. Please visit humana.com/
individual-and-family for a detailed list. Unless specifically stated otherwise, no benefits will be provided for, or on account
of, the following items:
Service and billing exclusions Dental, foot care, hearing, and vision occupation, employment or activity
• Services provided by a family services for compensation, profit or gain,
member or person who resides with • Dental services (except for dental whether or not benefits are available
the covered person injury), appliances, or supplies under Workers’ Compensation
• Services incurred before the effective • Foot care services except as stated in the policy
date, after the termination date, or • Hearing care that is routine except • Sickness or bodily injury as a result
when premium is past due as stated in the policy of war, armed conflict, participation
• Charges in excess of the maximum • Vision examinations or testing, in a riot, influence of an illegal
allowable fee or reimbursement limit eyeglasses, or contact lenses except substance, being intoxicated, or
• Charges in excess of any benefit as stated in the policy engaging in an illegal occupation
maximum
• Services not authorized, furnished, or Pregnancy and sexuality services Care in certain settings
prescribed by a healthcare provider • Elective medical or surgical abortion • Private duty nursing when confined
• Services for which no charge is made except as stated in the policy in a hospice facility
• Services rendered by a standby • Elective caesarean section delivery • Custodial or maintenance care
physician, surgical assistant, unless medically necessary • Care furnished while confined in
assistant surgeon, physician • Immunotherapy for recurrent a hospital or institution owned
assistant, nurse or certified operating abortion or operated by the United States
room technician unless medically • Home uterine activity monitoring government or any of its agencies
necessary • Reversal of sterilization for any service connected sickness or
• Services not medically necessary, • Infertility services bodily injury
except for routine preventive services • Sex change services and sexual
as stated in the policy dysfunction Hospital services
• Services rendered in a premenstrual • Services received in an emergency
Elective and cosmetic services syndrome clinic room unless required because of
• Cosmetic services, or any related emergency care
complication Obesity-related services • Charges for a hospital stay that
• Elective medical or surgical • Any treatment for obesity except as begins on a Friday or Saturday unless
procedures except elective tubal stated in the policy due to emergency care or surgery is
ligation and vasectomy • Surgical procedures for the removal performed on the day admitted
• Hair prosthesis, hair transplants, or of excess skin and/or fat due to • Hospital inpatient services when
hair implants weight loss the covered person is in observation
• Prophylactic services status or when the stay is due to
Illness/injury circumstances behavioral, social maladjustment,
Immunizations • Services or supplies provided in lack of discipline or other antisocial
• Immunizations except as stated in connection with a sickness or actions which are not the result of
the policy bodily injury arising out of, or mental health
sustained in the course of, any
GAHHWKAEN 1014 Page 7 of 12
POLICY NUMBER: GA-71037-01 4/2010Mental health services • Genetic testing, counseling, or use for a covered preventive service
• Court-ordered mental health services except as stated in the as recommended by the United
services unless medically necessary policy States Preventive Services Task Force
• Services and supplies that are • Hyperhidrosis surgery (USPSTF) with a prescription from a
rendered in connection with • Immunotherapy for food allergy healthcare practitioner
mental illnesses not classified in • Light treatment for Seasonal • Prescription refills exceeding the
the International Classification of Affective Disorder (S.A.D.) number specified by the healthcare
Diseases of the U.S. Department of • Living expenses, travel, practitioner or dispensed more
Health and Human Services transportation, except as stated in than one year from the date of the
• Services and supplies that are the policy original order
extended beyond the period • Prolotherapy; Sensory integration • Vitamins, dietary products, and any
necessary for evaluation and therapy other nonprescription supplements
diagnosis of learning and behavioral • Services for care or treatment of except as stated in the policy
disabilities or for mental retardation non-covered procedures, or any • Over the counter medical items
• Marriage counseling related complication or supplies that can be provided
• Alternative medicine including but or prescribed by a healthcare
Other payment available not limited to holistic medicine and practitioner but are also available
• Services furnished by or payable naturopathy without a written order or
under any plan or law through • Services that are experimental, prescription except for drugs
a government or any political investigational, or for research prescribed for use for a covered
subdivision, unless prohibited by law purposes preventive service
• Charges for which any other • Sleep therapy
insurance providing medical • Treatment for TMJ, CMJ, or any jaw Additional expenses not covered for
payments exists joint problem except as stated in the the following benefits:
policy
Services not considered medical • Treatment of nicotine habit or Pediatric Vision
• Charges for non-medical items addiction except FDA approved • Orthoptic or vision training and any
that are used for environmental smoking cessation drugs, associated testing
control or enhancement whether medications or supplies with a • Multiple pair of glasses in lieu of
or not prescribed by a healthcare prescription from a healthcare bifocals or trifocals
practitioner practitioner • Pre- and post-operative services;
• Any drug, medicine or device which medical or surgical treatment of the
Other is not FDA approved eye(s) or supporting structure
• Any expense incurred for services • Medications, drugs or hormones to • Services or materials required by an
received outside of the United stimulate growth employer; safety lenses and frames
States except as required by law for • Legend drugs not recommended or • Contact lenses when benefits are
emergency care services deemed necessary by a healthcare paid for frames and lenses
• Biliary lithotripsy; Chemonucleolysis practitioner or drugs prescribed for a • Oversized 61 and above lens or
• Charges for growth hormones non-covered bodily injury or sickness lenses; artistically painted lenses;
• Contraceptives when prescribed • Drugs prescribed for intended use premium lens options
for purposes other than to prevent other than for indications approved • Treatment related to or caused by
pregnancy by the FDA or recognized off label disease
• Cranial banding, unless otherwise indications through peer reviewed • Charges for missed appointments or
determined by us medical literature; experimental or completion of claim forms
• Educational or vocational training or investigational use drugs • Non-prescription materials or vision
therapy, services, and schools • Lawfully obtainable without a devices
• Expense for employment, prescription (over the counter • Costs for securing materials; routine
school, sports or camp physical drugs), except insulin, drugs, maintenance of materials
examinations or for the purpose medicines or medications on the • Refitting or change in lens design
of obtaining insurance, premarital Women’s Healthcare Drug List, with after initial fitting
tests/examinations a prescription from a healthcare • Orthokeratology
practitioner, or drugs prescribed for
GAHHWKAEN 1014 Page 8 of 12
POLICY NUMBER: GA-71037-01 4/2010Pediatric Dental (Available with Off occlusion, splinting teeth, including control, take-home items, or dietary Exchange Plans Only) multiple abutments or any service planning • Charges for precision or semi- to stabilize periodontally weakened • Replacement of any lost, stolen, precision attachments, overdentures teeth, replacing tooth structures lost damaged, misplaced or duplicate and any associated endodontic resulting from abrasion, attrition, major restoration, prosthesis or treatment, any customized erosion or abfraction, or bite appliance attachments, temporary and interim registration or analysis • Caries susceptibility testing, dental services, charges related • Hospital, surgical or treatment laboratory tests, saliva samples, to materials or equipment used in facility or for services of an anaerobic cultures, sensitivity delivery of dental care, or services anesthesiologist or anesthetist testing or charges for oral pathology for 3D imaging (cone beam images) • Prescription drugs or pre- procedures • Infection control including but not medications • Services performed by other than a limited to sterilization techniques • Orthodontic services or repair dentist except as expressly stated in • Charges for missed appointments or and replacement of orthodontic the policy completion of claim forms appliances • Services not eligible for benefits • Charges related to altering vertical • Preventive control programs based on a clinical review, does dimension of teeth or changing including but not limited to oral not offer a favorable prognosis, or the spacing and/or shape of the hygiene instructions, plaque does not have uniform professional teeth, restoration or maintenance of acceptance Offered by Humana Employers Health Plan of Georgia, Inc. and insured by Humana Insurance Company. Applications are subject to eligibility requirements. Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage call or write your Humana insurance agent or broker. GAHHWKAEN 1014 Page 9 of 12 POLICY NUMBER: GA-71037-01 4/2010
Add extra benefits for protection The following dental policies are available to you at an extra cost Make your Humana plan fit your needs even better. This extra benefit is an easy and affordable way to get the coverage you need. Dental Protect your healthy smile with affordable, easy-to-use optional dental benefits from one of the nation’s largest dental insurers. For a low monthly premium, you can use a provider located in more than 225,000 dentist locations. Just choose the type of coverage that meets your needs: Preventive Plus covers the most common preventive and basic services. Discounts are available for major services and basic services the plan doesn’t cover. Dental Savings Plan Plus is not insurance, but a discount plan that could save you 15-40% on many services, including dental, vision, Rx, hearing or alternative medicine. Preventive Plus Package for Veterans is exclusively for U.S. Veterans. It provides dental coverage at 100 percent for many in-network dental preventive procedures, low deductibles, no copayments, and offers many extras such as discount on vision, hearing, prescriptions, and clinic care services. These plans have limitations and exclusions, waiting periods, and terms under which the plans may be continued in force or discontinued. For more information, go to Humana.com or contact your sales agent. Insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., CompBenefits of Georgia, Inc., Humana Health Benefit Plan of Louisiana, Inc., DentiCare, Inc. (d/b/a CompBenefits), Discount plans offered by Texas Dental Plans, Inc. GAHHWKAEN 1014 Page 10 of 12
Notes __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ GAHHWKAEN 1014 Page 11 of 12 POLICY NUMBER: GA-71037-01 4/2010
GAHHWKAEN 1014 Page 12 of 12 POLICY NUMBER: GA-71037-01 4/2010
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