O-2004-2777 - Laserfiche WebLink

Browse Search

e CoverageFirst 1500 Plan 35, Option 100 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-Of-Pocket Expense Limit · Family (per calendar year) (excludes deductibles and copayments) $3.000 $9,000 $6,000 $18.000 Lifetime Maximum Benefit u,ooo,ooo Payments - Plan benefits are paid based on reasonable charges. as defined in your Certificate. Participating providers agree to accept reasonable charges. as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee sc/:1edule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges. as defined in your Certificate. Participating primary care and -pecialist physicians and other roviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent I " contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. '17Ie alllOl/llt oj benifits pTOlJided depends I/pOll the plan selected. Premiums U.'i/ll'tlty according to the selection /IIade. For general questiol/s abol/t the plan, conTact 1'O/4r benefits adminisrrator.