Summary of Benefits and Coverage: What this Plan Covers & What … · 2018-10-19 · S111517 1 of 8 SBC0157W111520171349INDC0003 Summary of Benefits and Coverage: What this Plan Covers

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SBC0157W111520171349INDC0003

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2018

HUMANA INSURANCE COMPANY: IN LG HUMANA PPO14 CFST OV&DED/COINS IP/OP Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would

share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.groupcertificate.humana.com or by

calling 1-866-4ASSIST (427-7478). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible,

provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-866-4ASSIST (427-7478) to

request a copy.

Important Questions Answers Why This Matters:

What is the overall

deductible?

Network: $1,000 Individual /

$2,000 family; Non-Network:

$3,000 Individual / $6,000 family

Doesn't apply to prescription

drugs and network preventive

services.

Coinsurance and copayments

don't count toward the deductible

$500.00Network benefit

allowance applies before

deductible. Does not apply to any

member copayments, Rx, or

preventive care.

Generally, you must pay all of the costs from providers up to the deductible amount before this

plan begins to pay. If you have other family members on the plan, each family member must

meet their own individual deductible until the total amount of deductible expenses paid by all

family members meets the overall family deductible.

Are there services

covered before you meet

your deductible?

Network Providers: Yes.

Preventive, Certain Office Visits,

Emergency Room Care, Urgent

Care, Prescription Drugs and

Certain Therapies.

Non-Network Providers: Yes.

Emergency Room Care and

Prescription Drugs.

This plan covers some items and services even if you haven't yet met the deductible amount. But

a copayment or coinsurance may apply. For example, this plan covers certain preventive

services without cost-sharing and before you meet your deductible. See a list of covered

preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other

deductibles for specific

services?

No You don't have to meet deductibles for specific services.

What is the out-of-pocket

limit for this plan?

For network providers $6,250

individual / $12,500 family; For

non-network providers

$18,000 individual / $36,000 family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other

family members in this plan, they have to meet their own out-of-pocket limits until the overall

family out-of-pocket limit has been met.

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What is not included in

the out-of-pocket limit?

Premiums, Balance-billing charges,

Health care this plan doesn't cover,

Penalties, Non-network transplant,

non-network prescription drugs,

non-network specialty drugs

Even though you pay these expenses, they don't count toward the out–of–pocket limit.

Will you pay less if you

use a network provider?

Yes. See

www.humana.com/directories or

call 1-866-4ASSIST (427-7478) for

a list of network providers

This plan uses a provider network. You will pay less if you use a provider in the plan's network.

You will pay the most if you use an out-of-network provider, and you might receive a bill from a

provider for the difference between the provider's charge and what your plan pays (balance

billing). Be aware, your network provider might use an out-of-network provider for some services

(such as lab work). Check with your provider before you get services.

Do you need a referral to

see a specialist?No You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common

Medical EventServices You May Need

Network Provider

(You will pay the least)

Non-Network Provider

(You will pay the most)

Limitations, Exceptions, & Other Important

Information

If you visit a health

care provider's office

or clinic

Primary care visit to treat an

injury or illness

$25 copay/office visit;

deductible does not

apply

50% coinsurance None

Specialist visit

$40 copay/visit;

deductible does not

apply

50% coinsurance None

Preventive care / screening /

immunizationNo charge 50% coinsurance

You may have to pay for services that aren't

preventive. Ask your provider if the services

you need are preventive. Then check what your

plan will pay for.

3 of 8

What You Will Pay

Common


Network Provider





Information

If you have a test

Diagnostic test (x-ray, blood

work)

No charge; deductible

does not apply50% coinsurance

Diagnostic Test:

Cost share may vary based on where service is

performed

Imaging:

Cost share may vary based on where service is

performed

Preauthorization may be required - if not

obtained, penalty will be 50%

Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance

If you need drugs to

treat your illness or

condition

More information about

prescription drug

coverage is available at

www.humana.com/2017-

Rx4

Scenario 24

Level 1 - Lowest cost generic

and brand-name drugs

$10 copay (Retail);

deductible does not

apply

$25 copay (Mail Order);

deductible does not

apply

30% coinsurance, after

network copay (Retail);

deductible does not apply


network copay (Mail

Order); deductible does

not apply

30 day supply


obtained, penalty will be 100% for certain

prescription drugs

(Retail)

90 day supply



prescription drugs

(Mail Order)

Non-network cost sharing does not count

toward the out-of-pocket limit.

Level 2 - Higher cost generic

and brand-name drugs

$30 copay (Retail);

deductible does not

apply


deductible does not

apply





network copay (Mail


not apply

4 of 8

What You Will Pay

Common


Network Provider





Information

Level 3 - Generic and

brand-name drugs with higher

cost than Level 2

$50 copay (Retail);

deductible does not

apply


deductible does not

apply





network copay (Mail


not apply

Level 4 - Highest cost drugs

25% coinsurance

(Retail); deductible does

not apply

25% coinsurance (Mail


not apply


network Coinsurance

(Retail); deductible does

not apply


network Coinsurance (Mail


not apply

Specialty Drugs

35% coinsurance;

deductible does not

apply

50% coinsurance;


25% coinsurance when filled via a preferred

network specialty pharmacy



prescription drugs

If you have outpatient

surgery

Facility fee (e.g., ambulatory

surgery center)20% coinsurance 50% coinsurance



Physician/surgeon fees 20% coinsurance 50% coinsurance None

If you need immediate

medical attention Emergency room care

$150 copay/visit;

deductible does not

apply

$150 copay/visit;


Emergency room care:

Copayment waived if admitted

Emergency medical

transportation20% coinsurance 20% coinsurance

Urgent care

$75 copay/visit;

deductible does not

apply

50% coinsurance

5 of 8

What You Will Pay

Common


Network Provider





Information

If you have a hospital

stay

Facility fee (e.g., hospital

room)20% coinsurance 50% coinsurance



Physician/surgeon fees 20% coinsurance 50% coinsurance None

If you need mental

health, behavioral

health, or substance

abuse services

Outpatient services

$25 copay/visit;

deductible does not

apply

50% coinsurance

Inpatient services:



Inpatient services 20% coinsurance 50% coinsurance

If you are pregnant

Office visitsNo charge; deductible

does not apply50% coinsurance

Office visits:

Cost sharing does not apply for preventive

services.

Childbirth/delivery professional services:

Depending on the type of services, a

coinsurance or deductible may apply.

Childbirth/delivery facility services:

Maternity care may include tests and services

described elsewhere in the SBC (i.e.

ultrasound) Preauthorization may be required -

if not obtained, penalty will be 50%

Childbirth/delivery professional

services20% coinsurance 50% coinsurance

Childbirth/delivery facility

services.20% coinsurance 50% coinsurance

If you need help

recovering or have

other special health

needs

Home health care 20% coinsurance 50% coinsurance

60 visit limit per cal yr/plan yr



6 of 8

What You Will Pay

Common


Network Provider





Information

Rehabilitation services

$40 copay/visit;

deductible does not

apply to

Manipulations,

Occupational Therapy,

Speech Therapy,

Audiology Therapy,

Cognitive Therapy, and

Physical Therapy

50% coinsurance

Therapies:



Manipulations and Therapies:

30 Physical Therapy, Occupational Therapy,

Speech Therapy, Cognitive Therapy,

Audiology Therapy visit limit per year includes

manipulations & adjustments

For non-network, 10 Physical Therapy,

Occupational Therapy, Cognitive Therapy,

Speech Therapy, Audiology Therapy visits per

year includes manipulations & adjustments

Habilitation services

$40 copay/visit;

deductible does not

apply to

Manipulations,

Occupational Therapy,

Speech Therapy,

Audiology Therapy,

Cognitive Therapy, and

Physical Therapy

50% coinsurance

Skilled nursing care 20% coinsurance 50% coinsurance

60 day limit per cal yr/plan yr



Durable medical equipment 20% coinsurance 50% coinsurance


obtained, penalty will be 50% for durable

medical equipment $750 and over

Excludes vehicle and home

modifications,exercise and bathroom

equipment

Hospice services 20% coinsurance 50% coinsurance None

If your child needs

dental or eye care

Children's eye exam Not Covered Not Covered None

Children's glasses Not Covered Not Covered None

Children's dental check-up Not Covered Not Covered None

7 of 8

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.)

• Acupuncture • Cosmetic Surgery • Non-Emergency Care, when traveling outside the U.S.

• Bariatric Surgery • Dental Care (Adult) • Private Duty Nursing

• Child Dental Check-Up • Hearing Aids • Routine eye care (Adult)

• Child Eye Exam • Infertility Treatment • Routine Foot Care

• Child Glasses • Long Term Care • Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Limitations may apply to these services as permitted by applicable law. These limitations are listed in your plan document.

• Chiropractic Care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those

agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol.gov/ebsa/healthreform or Department of

Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or http://www.cciio.cms.gov. Other coverage

options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the

Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a

grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also

provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,

contact:

• Humana, Inc.: www.humana.com or 1-866-4ASSIST (427-7478).

• Department of Labor Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform

• Indiana Department of Insurance, 311 West Washington Street, Suite 300, Indianapolis, IN 46204-2787, Phone: 317-232-2426, Email: [email protected],

Website: http://www.in.gov/idoi

Does this plan provide Minimum Essential Coverage? Yes.

If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the

requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

–––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page .–––––––––––––––––––––––

8 of 8

About these Coverage Examples:

The plan would be responsible for the other costs of these EXAMPLE covered services.

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be

different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing

amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion

of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing

Deductibles $1,000

Copayments $30

Coinsurance $2,000

What isn't covered

Limits or exclusions $0

The total Peg would pay is $3,030

Peg is Having a Baby

(9 months of in-network pre-natal care and a

hospital delivery)

The plan's overall deductible $1,000

Specialist copayment $40

Hospital (facility) coinsurance 20%

Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care)

Childbirth/Delivery Professional Services

Childbirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work)

Specialist visit (anesthesia)

Mia’s Simple Fracture

(in-network emergency room visit and follow up

care)






Emergency room care (including medical

supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches)

Rehabilitation services (physical therapy)


In this example, Joe would pay:

Cost Sharing

Deductibles $1,000

Copayments $1,100

Coinsurance $0

What isn't covered


The total Joe would pay is $2,120


In this example, Mia would pay:

Cost Sharing

Deductibles $200

Copayments $700

Coinsurance $0

What isn't covered


The total Mia would pay is $940

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-

controlled condition)






Primary care physician office visits (including

disease education)

Diagnostic tests (blood work)

Prescription drugs

Durable medical equipment (glucose meter)

What is CoverageFirst?With CoverageFirst, you can see any provider without a referral – but your costs are usually lower when you use in-network providers. What makes CoverageFirst unique is the $500-per-covered member “benefit allowance” that covers many services from in-network providers before you start paying toward your deductible.

Here’s how it works:

1. The plan pays the first $500 of eligible expenses from in-network providers. You just pay a copayment.

2. If you use the entire $500, you pay most additional expenses until you meet the annual deductible. The plan has a separate $500 allowance and a separate deductible for each family member; each person's costs also apply to a deductible for the entire family.

Why you might want CoverageFirstCoverageFirst offers lower premiums and a “safety net” in case of a major illness or injury.

• Your up-front costs are lower. CoverageFirst premiums are generally lower than with other plan types.• You could have very low out-of-pocket costs. Many health plan members spend less than $500 a year

on medical care.* If you’re in that group, the CoverageFirst allowance might cover all of your costs except your copayments.

• Preventive care coverage. Even if your $500 is gone, CoverageFirst covers your preventive care office visits. However, you would be responsible for special procedures billed separately, such as lab work.

• The out-of-pocket maximum provides peace of mind. If you have a serious illness or injury, your costs for covered services at in-network providers are capped.

Using your allowanceThe entire $500 is available on the first day of the plan year. You can use the allowance for:

• Doctor’s office visits• Routine outpatient laboratory tests and X-rays• Hospital services, including semiprivate room and board, emergency room services, and outpatient surgery• Other services such as home healthcare, physical therapy, and hospice care

Your allowance isn't depleted when you fill a prescription or receive mental health services. Also, the allowance doesn't cover copayments or any services from out-of-network providers. Check the summary plan description for details about plan benefits, limitations, and exclusions.

CoverageFirst®

How it works

GN14545HH 0513

Humana.com

Example one — Lynn (single coverage) Example two — Greg (family coverage)Lynn chooses a CoverageFirst plan with:• $500allowance• $3,000deductible• 100percentcoinsurance (in-network)

Greg chooses a CoverageFirst plan.Each covered member has:• $500allowance• $2,500deductible• 80percentcoinsurance (in-network)• $3,000out-of-pocketmaximum

(does NOT include the deductible)

Lynn goes to her primary care physician and finds out sheneeds some blood work.

Greg is injured in a fall. He goes to the emergency room and spends two days in the hospital. Later, he has a follow-up visit with a specialist.

• Doctor’s office visit(Lynn pays a $25 copayment)

$50 • Hospitalcare(Greg pays $500 in copayments)

$10,000

• Outpatient lab(no copayment)

$400 • Onespecialistvisit(Greg pays $50 copayment)

$150

How Lynn uses CoverageFirst How Greg uses CoverageFirstTotal cost of medical services $450 Total cost of medical services $10,150Lynn’s copayments $25 Deduct Greg’s total copayments (-$550)

CoverageFirst pays the remaining costs $425 Remaining cost of medical services $9,650

CoverageFirst pays $500 of remaining cost.

$9,150

Greg is now responsible for his deductible (-$2,500)

Remaining cost of medical services $6,650

Greg’s plan pays 80 percent of remaining cost, leaving Greg to pay 20 percent— $6,650x20%=$1,330

Summary SummaryLynn’s medical expenses for the calendar year didn’t exceed her $500 CoverageFirst allowance. The only medical expenses she paid were copayments totaling $25.

Greg’s out-of-pocket maximum is $3,000. He has met$1,330 (his deductible did not apply to the out-of-pocketmaximum). Greg must pay $1,670 more in medicalcosts until he reaches his out-of-pocket maximum. Thenhis plan will start paying 100 percent of the remainingmedical costs for the rest of his plan year.

* These examples may not apply to all lines of business (PPO, POS, HMO)

GN14545HH 0513

Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. - A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009 or administered by Humana Insurance Company or Humana Health Plan, Inc.For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits. Our health benefit plans have limitations and exclusions.

Humana.com

INDIANA

Floyd County Government

SGB0153A

Humana Dental PPO 09

Page 1 of 31-800-233-4013 • Humana.com

If you use anIN-NETWORK dentist

If you use anOUT-OF-NETWORK dentist

Calendar-year deductible(excludes orthodontia services)

Individual$50

Family$150

Individual$100

Family$300

Calendar-year annual maximum (excludes orthodontia services)

$1,000

Preventive services•Oral examinations•X-rays•Cleanings•Topical fluoride treatment (through age 14, one per

calendar year)•Sealants (through age 14)

100% no deductible 80% after deductible

Basic services •Space maintainers (through age 14)•Emergency care for pain relief•Basic oral surgery services - basic extractions of

erupted tooth or root•Fillings (amalgam, composite for anterior teeth)•Appliances for children (through age 14)•Prefabricated stainless steel crowns

80% after deductible 50% after deductible

do not delete

Major services•Crowns•Inlays and onlays•Bridgework•Dentures•Denture relines and rebases


•Complex surgical extractions - surgical removal oferupted tooth, impacted tooth, and tooth roots

•Periodontics (gums) •Endodontics (root canals)

do not delete

Orthodontia services If you do not choose orthodontia coverage, employees maybe eligible to receive up to a 20% discount on non-coveredservices. Members may contact a participating provider todetermine if any discounts are available.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDental plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist.


1-800-233-4013 • Humana.comPage 2 of 3

Waiting periods

Voluntary funding: 10+ enrolled employees

Enrollment type Preventive Basic Major Orthodontia Initial enrollment, open enrollment No No No Not availableand timely add-on

Late applicant 1, 2 No 12 months 12 months Not available

1 Late applicants not allowed with open enrollment option.2 Waiting periods do not apply to endodontic services unless a late applicant.

Questions? Simply call 1-800-233-4013 to speak witha friendly, knowledgeable Customer Carespecialist, or visit Humana.com.

Humana.com

Plan summary created on: 9/30/16 17:07

Feel good about choosinga HumanaDental plan Make regular dental visits a priorityRegular cleanings can help manage problemsthroughout the body such as heart disease, diabetes,and stroke.* Your HumanaDental PPO plan focuses onprevention and early diagnosis, providing four examsand cleanings every calendar year: two regular and twoperiodontal.* www.perio.org

Go to MyDentalIQ.comTake a health risk assessment that immediately ratesyour dental health knowledge. You’ll receive apersonalized action plan with health tips. You can print acopy of your scorecard to discuss with your dentist atyour next visit.

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes twice a day• Floss daily• Watch for signs of periodontal disease such as red,

swollen, or tender gums• Visit a dentist regularly for exams and cleanings

Did you know that 74 percent of adult Americans believe anunattractive smile could hurt a person’s chances for careersuccess?* HumanaDental helps you feel good about your dentalhealth so you can smile confidently.* American Academy of Cosmetic Dentistry

Use your HumanaDentalbenefitsFind a dentistWith HumanaDental’s PPO plan, you can see any dentist.Members and their families benefit from negotiateddiscounts on covered servcies by choosing dentists in theHumanaDental PPO Network. To find a dentist inHumanaDental’s PPO Network, log on to Humana.com orcall 1-800-233-4013.

Know what your plan coversThe other side of this page gives you a summary ofHumanaDental benefits. Your plan certificate describesyour HumanaDental benefits, including limitations andexclusions. You can find it on MyHumana, your personalpage at HumanaDental.com or call 1-800-233-4013.

See your dentistYour HumanaDental identification card contains all theinformation your dentist needs to submit your claims. Besure to share it with the office staff when you arrive foryour appointment. If you don’t have your card, you canprint proof of coverage at Humana.com .

Learn what your plan paidAfter HumanaDental processes your dental claim, you willreceive an explanation of benefits or claims receipt. Itprovides detailed information on covered dental services,amounts paid, plus any amount you may owe yourdentist. You can also check the status of your claim onMyHumana at Humana.com or by calling1-800-233-4013.

Policy Number: IN-70090-HD 3/08 et.al.

Humana group dental plans are offered by Humana Insurance Company, HumanaDental Insurance Company, Humana InsuranceCompany of New York, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc., Humana Medical Plan of Utah,CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc. or DentiCare, Inc. (d/b/aCompBenefits)

This is not a complete disclosure of plan qualifications and limitations. Your agents will provide you with specific limitations andexclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying forcoverage. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made.


Page 3 of 3

INDIANA


SGB0153A

Humana Dental TraditionalPreferred 09

Page 1 of 31-800-233-4013 • Humana.com

If you use anIN-NETWORK dentist

If you use anOUT-OF-NETWORK dentist

Calendar-year deductible(excludes orthodontia services)

Individual$50

Family$150

Individual$50

Family$150

Calendar-year annual maximum (excludes orthodontia services)

$2,000

Preventive services•Oral examinations•X-rays•Cleanings•Topical fluoride treatment (through age 14, one per

calendar year)•Sealants (through age 14)

100% no deductible 100% no deductible

Basic services •Space maintainers (through age 14)•Emergency care for pain relief•Basic oral surgery services - basic extractions of

erupted tooth or root•Fillings (amalgam, composite for anterior teeth)•Appliances for children (through age 14)•Prefabricated stainless steel crowns


•Periodontics (gums) •Endodontics (root canals) do not delete

Major services•Crowns•Inlays and onlays•Bridgework•Dentures•Denture relines and rebases


•Complex surgical extractions - surgical removal oferupted tooth, impacted tooth, and tooth roots

•Denture repair and adjustmentsdo not delete

Orthodontia services If you do not choose orthodontia coverage, employees maybe eligible to receive up to a 20% discount on non-coveredservices. Members may contact a participating provider todetermine if any discounts are available.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDental plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. If a member sees an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule in your area.

Humana Dental Traditional Preferred 09

1-800-233-4013 • Humana.comPage 2 of 3

Waiting periods

Voluntary funding: 10+ enrolled employees

Enrollment type Preventive Basic Major Orthodontia Initial enrollment, open enrollment No No No Not availableand timely add-on

Late applicant 1, 2 No 12 months 12 months Not available

1 Late applicants not allowed with open enrollment option.2 Waiting periods do not apply to endodontic services unless a late applicant.

Questions? Simply call 1-800-233-4013 to speak witha friendly, knowledgeable Customer Carespecialist, or visit Humana.com.

Humana.com


Feel good about choosinga HumanaDental plan Make regular dental visits a priorityRegular cleanings can help manage problemsthroughout the body such as heart disease, diabetes,and stroke.* Your HumanaDental Traditional Preferredplan focuses on prevention and early diagnosis,providing four exams and cleanings every calendar year:two regular and two periodontal.* www.perio.org

Go to MyDentalIQ.comTake a health risk assessment that immediately ratesyour dental health knowledge. You’ll receive apersonalized action plan with health tips. You can print acopy of your scorecard to discuss with your dentist atyour next visit.

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes twice a day• Floss daily• Watch for signs of periodontal disease such as red,

swollen, or tender gums• Visit a dentist regularly for exams and cleanings

Did you know that 74 percent of adult Americans believe anunattractive smile could hurt a person’s chances for careersuccess?* HumanaDental helps you feel good about your dentalhealth so you can smile confidently.* American Academy of Cosmetic Dentistry

Use your HumanaDentalbenefitsFind a dentistWith HumanaDental’s Traditional Preferred plan, you cansee any dentist. Members and their families benefit fromnegotiated discounts on covered servcies by choosingdentists in the HumanaDental Traditional PreferredNetwork. To find a dentist in HumanaDental’s TraditionalPreferred Network, log on to Humana.com or call1-800-233-4013.

Know what your plan coversThe other side of this page gives you a summary ofHumanaDental benefits. Your plan certificate describesyour HumanaDental benefits, including limitations andexclusions. You can find it on MyHumana, your personalpage at HumanaDental.com or call 1-800-233-4013.

See your dentistYour HumanaDental identification card contains all theinformation your dentist needs to submit your claims. Besure to share it with the office staff when you arrive foryour appointment. If you don’t have your card, you canprint proof of coverage at Humana.com .

Learn what your plan paidAfter HumanaDental processes your dental claim, you willreceive an explanation of benefits or claims receipt. Itprovides detailed information on covered dental services,amounts paid, plus any amount you may owe yourdentist. You can also check the status of your claim onMyHumana at Humana.com or by calling1-800-233-4013.

Policy Number: IN-70090-HD 3/08 et.al.

Humana group dental plans are offered by Humana Insurance Company, HumanaDental Insurance Company, Humana InsuranceCompany of New York, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc., Humana Medical Plan of Utah,CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc. or DentiCare, Inc. (d/b/aCompBenefits)

This is not a complete disclosure of plan qualifications and limitations. Your agents will provide you with specific limitations andexclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying forcoverage. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made.

Humana Dental TraditionalPreferred 09

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INDIANA


SGB0169A

Humana Vision 100

Humana.com Page 1 of 5

Vision care servicesIf you use anIN-NETWORK provider(Member cost)

If you use anOUT-OF-NETWORK provider(Reimbursement)

Exam with dilation as necessary •Retinal imaging 1

$10Up to $39

Up to $30Not covered

Contact lens exam options2•Standard contact lens fit and follow-up•Premium contact lens fit and follow-up

Up to $5510% off retail

Not coveredNot covered

Frames3 $100 allowance20% off balance over $100

$50 allowance

Standard plastic lenses4•Single vision•Bifocal•Trifocal•Lenticular

$25$25$25$25

Up to $25Up to $40Up to $60Up to $100

Covered lens options4•UV coating•Tint (solid and gradient)•Standard scratch-resistance•Standard polycarbonate - adults•Standard polycarbonate - children <19•Standard anti-reflective coating•Premium anti-reflective coating

z- Tier 1- Tier 2- Tier 3

•Standard progressive (add-on to bifocal)•Premium progressive

- Tier 1- Tier 2- Tier 3- Tier 4

•Photochromatic / plastic transitions•Polarized

$15 $15 $15 $40 $40 $45 Premium anti-reflective coatings as follows:

$57 $68 80% of charge$25 Premium progressives as follows:$110 $120 $135 $90 copay, 80% of charge less $120 allowance$75 20% off retail

Not coveredNot coveredNot coveredNot coveredNot coveredNot coveredPremium anti-reflective coatings as follows:Not coveredNot coveredNot coveredUp to $40Premium progressives as follows:Not coveredNot coveredNot coveredNot coveredNot coveredNot covered

Contact lenses5 (applies to materials only)•Conventional

x•Disposable•Medically necessary

$100 allowance,15% off balance over $100$100 allowance$0

$80 allowance

$80 allowance$200 allowance

Humana Vision 100

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Vision care servicesIf you use anIN-NETWORK provider(Member cost)

If you use anOUT-OF-NETWORK provider(Reimbursement)

Frequency •Examination•Lenses or contact lenses•Frame

Once every 12 monthsOnce every 12 monthsOnce every 24 months

Once every 12 monthsOnce every 12 monthsOnce every 24 months

Diabetic Eye Care: care andtesting for diabetic members•Examination

- Up to (2) services per year •Retinal Imaging

- Up to (2) services per year •Extended Ophthalmoscopy

- Up to (2) services per year •Gonioscopy

- Up to (2) services per year •Scanning Laser

- Up to (2) services per year

$0

$0

$0

$0

$0

Up to $77

Up to $50

Up to $15

Up to $15

Up to $33

Optional benefitsXDONOTDELETE

1. Member costs may exceed $39 with certain providers. Members may contact their participating provider to determine what costs or discounts are available.

2 Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discounts are available.

3 Discounts may be available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed

costs are available. 5 Plan covers contact lenses or frames, but not both.XDONOTDELETE

Additional plan discounts•Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact

their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMedProvider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts orpromotional offers. Services or materials provided by any other group benefit plan providing vision care may not becovered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes ano-discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair ofeyeglasses. If purchased separately, members receive 20% off the retail price.

•Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US LaserNetwork, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure,performed by specialty trained providers, this discount may not always be available from a provider in yourimmediate location.

Vision health impactsoverall health

Routine eye exams can leadto early detection of visionproblems and other diseasessuch as diabetes, hypertension,multiple sclerosis, high bloodpressure, osteoporosis, andrheumatoid arthritis 1.

1 Thompson Media Inc.


Humana Vision products insured by Humana InsuranceCompany, Humana Health Benefit Plan of Louisiana, TheDental Concern, Inc. or Humana Insurance Company ofNew York.

This is not a complete disclosure of the planqualifications and limitations. Specific limitations andexclusions as contained in the Regulatory and TechnicalInformation Guide will be provided by the agent. Pleasereview this information before applying for coverage.

NOTICE: Your actual expenses for covered services mayexceed the stated cost or reimbursement amountbecause actual provider charges may not be used todetermine insurer and member payment obligations.

Policy number: IN-70148-019/15et.al.Page 3 of 5

Limitations and Exclusions:In addition to the limitations and exclusions listed in your "Vision Benefits" section,this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker’s compensation or

occupational disease act or law, whether or not you applied for coverage.2. Services:

•That are free or that you would not be required to pay for if you did not have thisinsurance, unless charges are received from and reimbursable to the U.S.government or any of its agencies as required by law;

•Furnished by, or payable under, any plan or law through any government or anypolitical subdivision (this does not include Medicare or Medicaid); or

•Furnished by any U.S. government-owned or operated hospital/institution/agencyfor any service connected with sickness or bodily injury.

3. Any loss caused or contributed by:•War or any act of war, whether declared or not;•Any act of international armed conflict; or•Any conflict involving armed forces of any international authority.

4. Any expense arising from the completion of forms.5. Your failure to keep an appointment.6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or

anesthetist.7. Prescription drugs or pre-medications, whether dispensed or prescribed.8. Any service not specifically listed in the Schedule of Benefits.9. Any service that we determine:

•Is not a visual necessity;•Does not offer a favorable prognosis;•Does not have uniform professional endorsement; or•Is deemed to be experimental or investigational in nature.

10. Orthoptic or vision training.11. Subnormal vision aids and associated testing.12. Aniseikonic lenses.13. Any service we consider cosmetic.14. Any expense incurred before your effective date or after the date your coverage

under this policy terminates.15. Services provided by someone who ordinarily lives in your home or who is a family

member.16. Charges exceeding the reimbursement limit for the service.17. Treatment resulting from any intentionally self-inflicted injury or bodily illness.18. Plano lenses.19. Medical or surgical treatment of eye, eyes, or supporting structures.20. Replacement of lenses or frames furnished under this plan which are lost or

broken, unless otherwise available under the plan.21. Any examination or material required by an Employer as a condition of

employment.22. Non-prescription sunglasses.23. Two pair of glasses in lieu of bifocals.24. Services or materials provided by any other group benefit plans providing vision

care.25. Certain name brands when manufacturer imposes no discount.26. Corrective vision treatment of an experimental nature.27. Solutions and/or cleaning products for glasses or contact lenses.28. Pathological treatment.29. Non-prescription items.30. Costs associated with securing materials.31. Pre- and Post-operative services.32. Orthokeratology.33. Routine maintenance of materials.34. Refitting or change in lens design after initial fitting, unless specifically allowed

elsewhere in the certificate.35. Artistically painted lenses.

Humana Vision plans help employees get and stay well

Humana.com

GCHJL5DEN 1116

Humana Vision products insured by Humana Insurance Company, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc. or Humana Insurance Company of New York.Go365 is not an insurance product. Not available with all Humana health plans.

Our plans include an annual eye exam and additional services for diabetes eye care to help keep your employees healthy. Go365TM members can even earn Points for getting their annual eye exams.

Brain• Tumor• Aneurysm

Heart• High blood

pressure • High

cholesterol

• Diabetes

• Glaucoma• Cataracts• Macular degeneration• Diabetic and

hypertensive retinopathy

An eye-care professional can provide early detection of diseases and conditions including:

Eyes

Kidneys

Did you know?

Documents

Summary of Benefits and Coverage: What this Plan Covers & What … · 2018-10-19 · S111517 1 of 8 SBC0157W111520171349INDC0003 Summary of Benefits and Coverage: What this Plan Covers