Advocate Health Care Network Plan-Humana PPO - Advocate Benefits

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Advocate Health Care Network Plan-Humana PPO Coverage Period: 01/01/2013 – 12/31/2013 Summar y of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: PPO • Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider’s office or clinic Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance ---none--- Specialist visit 20% coinsurance 40% coinsurance ---none--- Other practitioner office visit 20% coinsurance 40% coinsurance Preventive care/screening/immunization No Charge 40% coinsurance Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Limitations & Exceptions 20 visits per benefit period for Chiropractic & Osteopathic Manipulations. Routine mammograms limited to one per year Immunization coverage/limitations are based on CDC guidelines If you have a test Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance ----none----
Advocate Health Care Network Plan-Humana PPO Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: PPO Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com If you have outpatient surgery Services You May Need Value Generic drugs Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Your Cost If Your Cost If You You Use an Use an In-network Out-of-network Provider Provider $3.33 for 30 day supply at retail/ $9.99 for 90 day supply via mail order $15 for 30 day supply at retail / $30 for 90 day supply via mail order $45 for 30 day supply at retail / $100 for 90 day supply via mail order $75 for 30 day supply at retail / $160 for 90 day supply via mail order Preferred Specialty Drugs same as Preferred Brand Drugs;Non-Preferred Specialty Drugs same as Non-Preferred Brand Drugs Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Physician/surgeon fees 20% coinsurance 40% coinsurance Limitations & Exceptions ----none---- ----none---- ----none---- ----none---- Specialty Drugs must be obtained through Caremark Specialty pharmacy and are only available in 30-day supply Pre authorization may be required. Your cost if prior authorization is not received is 50%. If you need immediate medical attention If you have a hospital stay Emergency room services $200 copay plus 20% coinsurance $200 copay plus 40% coinsurance Emergency medical transportation 20% coinsurance 20% coinsurance ---none--- Urgent care 20% coinsurance 40% coinsurance ---none--- Copay waived if admitted. If a true emergency, covered at the 20% coinsurance. Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Preauthorization applies. Your cost if prior authorization is not received is 50%. Physician/surgeon fee 20% coinsurance 40% coinsurance ---none---
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Advocate Health Care Network Plan-Humana PPO - Advocate Benefits

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